School-Based Telehealth Makes Health a Priority for Teachers, Providers

A Home-Grown Recipe for Student Care

In North Carolina, Atrium Health – formerly Carolinas HealthCare – is spearheading one of the nation’s newer school-based telehealth programs.

“We grew this right in our own hometown,” said Patricia Grinton, director of children’s telemedicine for Atrium Health. “We found what worked, what was successful, and then we branched out to other towns.”

For Grinton, “this” is a telehealth platform that is slowly and carefully expanding from the Levine Children’s Clinic in Shelby to schools and school districts in North Carolina. And it’s doing so by creating a community around that platform that includes schools, local pediatricians and civic leaders.

“You can’t succeed unless you’ve got support from the whole community,” she says.

Launched in 2017, Atrium’s school telehealth network has targeted small schools in areas where poverty and unemployment are high and insurance and access to primary care are scarce. Armed with grants from the likes of Kohl’s and Blue Cross and Blue Shield of North Carolina, the network gives students in member schools access to primary care services they might otherwise not get.

Grinton said the going is slow and painful – she’s had to deal with “a couple years of shoestring budgets” – but progress is steady. Studies have found that a telehealth program targeting the four most common non-acute illnesses in children cut the number of children taken out of school to see their doctor or sent to a clinic or the hospital by one-third.

“We can have these great outcomes, but if nobody really knows about it, it is hard to get support,” she said.

For that support, Grinton said, it’s important to build a network. Get the school nurses and teachers on board first because they’ll be the ones to use the platform and tout its merits to skeptical parents. Make sure the platform helps nurses rather than giving them more to do, and then make sure that service is supported by the community.

In establishing a link with local care providers, Grinton advises to start small with volunteers.

“We were very strategic, and we started with just a couple of physicians,” she said. “You don’t want too many cooks in the kitchen, and you don’t want this to be complicated. Establish a routine, and then you can expand as needed.”

How Telehealth Makes a Difference

At the Delhi Unified School District in California’s San Joaquin Valley, the benefits of having telehealth are noticeable and extensive. In this five school, 2,700-student district in Delhi, the largest unincorporated town in Merced County, healthcare “is not an area of expertise for us,” said District Superintendent Adolfo Melara.

“We provided what we could with nurses, but we didn’t have the resources to do what we should be doing for these kids,” he said.

The district began talks with telehealth company Hazel Health in 2017, and rolled out a telehealth platform in 2018, linking the three elementary, one middle and one high school with local primary care providers and the nearest health system through iPads.

“We saw things change almost immediately,” said Melara. “Now most kids are taking advantage of it. And we know that almost anyone who comes through the doors (of the nurse’s office), we’re going to be able to take care of it.”

As evidenced by the colorful website, Delhi USD is a close-knit, rural community with a strong immigrant flavor (some 40 percent of the district’s students use English as a second language). Melara said the district takes pride in giving its students the tools they need to make the most of an education – and it’s always looking to improve upon those resources.

“As a superintendent, I’m always wondering what we can do for our students to improve their learning,” he said. “And we see health as being just as important as our classes. So anything we can do to keep our students healthy and in class is vital.”

And in a state that figures average daily attendance into education funding, it’s important to keep those students in class.

With Hazel Health providing a “coherence of service” and developing healthcare as a community resource, Melara has seen a roughly 20 percent reduction in absenteeism in his district, and a roughly 30 percent reduction in students leaving class to take care of chronic care needs.

And they’re feeling it, too.

“This community has a sense of pride in what we offer,” he said, noting that Delhi USD is becoming a model for other school districts thinking of launching a telehealth platform. “These parents now see us and that say, ‘My child has access to high-level medical care right in the school.’”

Partnering With a Telehealth Provider

While some school-based telehealth programs are home-grown, others are coordinated by telehealth companies. One of the newer and more unique providers in this ever-evolving market in Hazel Health, a San Francisco-based organization launched in 2015 and now operating in roughly half a dozen states.

“In many states, school funding is tied to attendance,” said Josh Golomb, the company’s CEO. “In some states like California, this can be higher than $50 a day per student. Hazel helps keep students healthier, which translates to significantly fewer student absences. This means that schools using Hazel may recover some of their lost attendance-based revenue when students are able to return to class versus having to go home for a minor health concern.”

“In addition, we are actively working with insurance companies and state Medicaid programs to fund the program,” he said. “They have seen our ability to improve access to health, reduce unnecessary emergency room visits and improve key health outcomes.  We will begin rolling out some of these partnerships in the coming months.”

Golomb said paying for telehealth isn’t the biggest barrier for schools – fitting the technology and services together is. Each school district – sometimes each school – has its own policies and rules to follow.

“Hazel has a unique opportunity to triage the care coordination that happens inside and outside schools,” he said. “We have seen many instances where connecting the school nurse, provider, and family has allowed us to create a stronger care plan for a chronically absent student.”

To succeed in what is often a tight-knit school environment, Golomb said, companies like Hazel Health “have to find a way to be part of the community.” In some cases that means taking the emphasis off of the word “telehealth” or “telemedicine” and focusing on community-based healthcare or connected health services.

“We’re not setting things up so that we have a group of people who pop in for a half-hour a day,” he said. “We’re creating a community health resource that’s part of the fabric of that community.”

Bringing Telehealth Into the School Setting

Based on statistics compiled by the California-based Center for Connected Health Policy, roughly two-thirds of the states have addressed telehealth in schools through legislative action – up from 23 states identified in a 2017 report by the American Telemedicine Association. The most common action establishes the school as an originating site for telehealth services, either through definition or, more importantly, for reimbursement through the state’s Medicaid program.

"When schools are unable to bill for these services, it often means the use of the service is not financially feasible,” New York Assemblywoman Addie A.E. Jenne said when her bill was signed into law in 2017. “By adding schools to the list of originating sites, schools will have a greater ability to consider telehealth services when needed for their students.”

“If the Medicaid reimbursement isn’t there, you’re not going to make it,” North says.

At that time, Medicaid reimbursement was seen as a key element to the sustainability of a school telehealth program.

“If the Medicaid reimbursement isn’t there, you’re not going to make it,” Steve North, then medical director and founder of the North Carolina-based Center for Rural Health Innovation, told Politico in a July 2017 interview. “You’re not even going to come close.”

“If we continue to weaken access points for low-income kids, then the schools are going to be having to figure out a way to meet those needs,” added John Schlitt, president of the School-Based Health Alliance, billed as the nation’s leading advocate of school-based clinics. “There’s only so many ways in which states are going to be able to absorb that kind of a financial cut.”

The landscape has evolved in three years. With more school districts looking for help and more health systems looking to offer those kinds of services, the opportunities are there for collaboration and new ideas.

Dotting the ‘i’s And Crossing the ‘t’s

Every school-based telehealth program should start with paperwork.

Start with a needs assessment from all the players, including the parents, Martin said. If there’s a large health system nearby doing all the work that a telehealth platform would do, a school-based telehealth service might not be needed or effective.

Next, telehealth encounters in school need the expressed written consent of a parent or guardian. In many school districts, that means getting their signatures on a form letter at the beginning of the school year so that it’s on file and can be pulled out when a child needs medical care.

One state taking a unique approach to this is Oklahoma. In May 2019, Governor Kevin Stitt signed a law modifying the state’s “Parent’s Bill of Rights” to enable them to approve the use of telehealth for their children in school.

The new law solidifies parental consent for telehealth and gives school districts and any partnering healthcare providers the leeway to choose the technology, provided it meets other state and medical board guidelines. It also establishes that written consent from a parent or legal guardian is good for the entire school year and must be renewed each year, and notes that the “health professional shall not be required to verify that the parent is at the site.”

The law also modifies state guidelines for the delivery of telemental health services. Previously, the healthcare provider had to verify the identity of the parent or guardian at the site where consent is given; now, telemental health is allowed as long as written consent is in place.

Then there’s the paperwork associated with funding.

Nix said grant funding can be a blessing and a curse – a blessing because the money keeps a program going, but a curse in that it often calls for a lot of paperwork and data collection. Sometimes collecting data is more difficult than actually running the telehealth program, resulting in extra work and stress that might ultimately doom the project.

And those grants do run out eventually.

“We’re very successful (in some schools), but guess what – when the grant ran out, the schools said ‘We’re done,’” Robbins pointed out.

In that case, organizations like Tift could pick up the tab – the health system is seeing students in Savannah, some four hours distant, and it’s keeping Nix’s program up and running.  But not every state has that kind of resource.

Up in North Carolina, Martin’s program has been supported by a grant from the Duke Endowment. She said funding organizations are often drawn to school-based telehealth programs because they help children in need.

“A lot of funders like that,” she said.

Paying for a School Telehealth Program

Beyond the grants and cash awards, school-based telehealth programs - like any other connected health program - look to payers to create sustainability. Many programs bill what they can to the student’s (or, in the case of staff, the school district’s) health plan. Some, like Hazel Health, forego reimbursement and focus on creating value to the schools, either in reduced expenses or more state funding.

But for many programs, the target population is covered by Medicaid. Medicaid may offer some reimbursement – a welcome relief to a student population that often lacks the resources to pay for primary care – but it doesn’t cover every student.

“You’re not going to get rich doing school-based telehealth – not if you’re doing it right, which means taking care of every single kid,” said Amanda Martin, who oversees the 88-school Health-E Schools program run by the Center for Rural Health Innovation in North Carolina.

Speaking at last year’s Xtelligent Healthcare Media’s 2019 Telehealth Summit, Martin said her independent program, serving some of North Carolina’s poorest school districts, gets $52 from the state Medicaid program for each student it saves from going to the local ER for treatment of an earache.

But that trip to the ER could cost upwards of $250 – money taken out of the local hospital’s revenue stream. That might make health systems – particularly rural providers struggling to make ends meet – wary of school telehealth programs.

“We need to make sure that who’s saving money has some skin in the game,” she said.

In that case, she said, care providers need to be cognizant of the value of downstream referrals, and of providing care for students, their families and even school staff for whom the in-school telehealth program doesn’t fit their needs. A hospital that takes part in a school-based telehealth program could thus position itself as the care provider of choice for that population.

“You’re not going to get rich doing school-based telehealth – not if you’re doing it right, which means taking care of every single kid,” Martin insists. 

The same goes for local primary care providers, said Robbins, of Georgia’s Tift Regional Health Systems. They might have no interest in a program that takes patients away from them, but if the school telehealth program pledges to refer patients to the local doctor or practice, that might be more attractive.

Consider the effect on the child and parents as well, he said. Consider a child coming down with a cold on a Wednesday. That trip to the doctor’s office or hospital might not happen for a day or two, meaning the child stays out of school for a few days, through the weekend. Maybe a prescription can’t be picked up until Monday or Tuesday, and through it all the parent may also be taking time off from work.

A school telehealth program can also help reduce stress on local hospitals, Robbins added.

“It’s not just $250 (from Medicaid) - it’s a CT scan of the sinus. It’s an entire workup (because) the ER doctor does not know that child,” he said. A telehealth service, on the other hand, puts a child in front of a primary care provider who knows what’s going on and can render treatment more efficiently and quickly.

“The dollars and cents don’t always make sense,” noted Nix, of the Georgia Partnership for Telehealth.

She urged communities, school districts and health systems to think outside the box when exploring the ROI for a school-based telehealth program. While local hospitals might like to keep those cases out of their ER, local businesses may see the program as a means of keeping their employees happy and on the job, rather than taking days off or running over to the school to take a sick child home or to the doctor’s office. Civic and faith-based organizations might see the program as an attractive selling point to potential residents and new business.

The biggest reportable impact, stressed Martin, is the return-to-class rate and graduation rate. Those are statistics that can be measured, she said, even if “it’s not a box you can tick in the EHR.”

At the end of the day, Robbins said, the focus should be on taking care of children in need of care.

“There is no better way to learn how to manage your healthcare population than a school-based program because you have a captive audience,” he said.  “You will see the benefits in your community, … but you won’t make a profit.”

Collateral Benefits and Challenges for School Telehealth

School-based telehealth programs start with primary care services but more and more are looking beyond that to other concerns, like behavioral health or chronic care management.

“Don’t have your blinders on,” Nix said. “You’re not serving the needs of kids unless you’re taking care of the whole kid.”

But that isn’t as easy. Behavioral health treatment often involves a whole extra layer of parental involvement.

“We can present a child with a broken bone without a parent, but we can’t present a child with a behavioral health issue without a parent,” said Robbins, who sees behavioral health is the biggest unmet health need in schools.

While many school districts and health systems are exploring how to integrate telemental health services in a school setting, Nix notes that a telehealth platform is a good place to start, and a way of identifying students so that they can be referred to specialists.

“One of the things we’re able to do is convert a stomach-ache into a mental health referral,” she said. It’s “another layer of triage.”