When Mark Garrett arrived in McDowell County Schools in North Carolina as assistant superintendent in 2012, unemployment in the rural, high-poverty community was 13%. And when he took the top job in the district a year later, he kept focusing on access to healthcare as one way to improve outcomes for students.

“Sometimes as a superintendent, you just have to be smart enough to say yes,” Garrett said of learning about Health-e-Schools, a school-based telehealth program created by the Center for Rural Health Innovation (CRHI) in Spruce Pine, North Carolina.

But he wasn’t interested in running a pilot. He wanted the program fully implemented in every school, Head Start and Early Head Start site in the 6,000-student district. “I’m big on what I call eliminating excuses.”

Through a partnership with Mission Health, based in Asheville, North Carolina, the telehealth program is also addressing the needs of students with complex mental health issues, who otherwise would have to make the 45-minute trip for an appointment, probably missing school and causing a parent to miss work. Now students can see a provider and still get back to class before the school day ends. 

The arrangement has “allowed us to probably get some families … on board” who otherwise would not have sought help for their child, Garrett said in an interview. “This helps us almost be a school-based health center.”

At a time when educators and policymakers are calling for increases in school counselors, psychologists and social workers, connecting students to these professionals in a virtual setting is one way that the rise of telehealth programs in schools is reducing absenteeism and improving students’ — and often employees’ — access to healthcare.

In another recent example, the Southwestern District Health Unit in North Dakota is piloting a program in which students at Dickinson Middle School will have virtual access to physicians with the Center for Psychiatric Health in Grand Forks, about five hours away.

And several districts in Texas are participating in the Telemedicine Wellness, Intervention, Triage and Referral Project through a state grant to the Texas Tech University Health Sciences Center. Students identified with “risk-based behaviors” are referred to counseling sessions through the project and then referred for further services if needed.

In many rural areas, behavioral health providers often see students in multiple spread-out districts and schools. Allowing them to meet with students virtually is an “excellent application for using telehealth,” Amanda Martin, the executive director of the CRHI, said in an interview. It’s a way to “divvy a provider up without them spending all their time in the car.” 

‘Great promise to increase access’

School-based telehealth initiatives received a boost in 2016, when the Federal Office of Rural Health Policy and the Health Resources and Services Administration (HRSA) provided grants totaling more than $6 million for rural telehealth programs and encouraged applications focused on expanding access to healthcare through school-based health centers (SBHC). This year, HRSA awarded $11 million to 120 SBHC in 32 states, which can be used for upgrades, including telehealth equipment.

Telehealth programs are also expanding at a time when many schools lack nurses — an issue that was among the reasons teachers in both Los Angeles and Oakland, California, went on strike earlier this year. But experts say virtual visits with a medical professional are more effective when school nurses are involved.

School nurses “are more effective at triaging who really has the greatest needs for telehealth services,” Laurie Combe, president-elect of the National Association of School Nurses (NASN), said in an interview. “School nurses have expertise in care coordination for students with chronic health conditions. For rural communities and for impoverished communities, telehealth facilitated by school nurses has great promise to increase access to care.”

That was what Hazel Health, a San Francisco-based company, realized after piloting an earlier version of its telehealth program, then called HippoMD, in the Sacramento Unified School District in California. Nurses there initially complained that the social workers facilitating the virtual appointments with the doctors lacked the clinical training to make proper referrals to the telehealth providers. But with Hazel Health — now in 12 districts in California and serving 15,000 students — nurses are a more integral part of the service.

“Hazel Health is a different company today,” Josh Golomb, the company’s CEO, said in an email. “Our school nurses and health personnel are superheroes and critical to making Hazel successful, and we’re grateful to them for facilitating and managing children’s health programs every day.”

One of those nurses is Ligaya Santos, who oversees health services for the almost 900-student Planada Elementary School District, east of Merced, in California’s San Joaquin Valley.

“I’ve been able to provide the children with a higher level of care” since the two-school district began working with Hazel Health, she said. “I’ve also been able to spend more time with the kids, since Hazel has taken on some of the mundane administrative duties that used to consume a good chunk of my time.”

Telehealth programs can “enhance” a typical visit to the school nurse’s office, Martin said. Normally, if nurses determine that the child’s symptoms warrant leaving school and seeing a doctor, they try to get a parent on the phone, which may or may not happen. And if a parent does sign a child out of school, there’s the “pain point” of not knowing whether the child will see a provider.

“We have kind of a health desert out here,” José González, superintendent of the Planada district, said in an interview. Families might wait two weeks for an appointment, he said.

Picking up a child in the middle of the school day is also a strain on the parents, many of whom work factory and other blue-collar jobs. “When they miss time to come pick up a child, there’s no sick leave,” he said. “It’s a day’s loss of wages.”

Now when a Planada student has been “Hazeled” — they’ve made it a verb — he or she most likely returns to class and the school sees “the value of preventing the loss of instructional minutes,” González said. Students, Santos said, also spend less time sitting in the nurse’s or school office in limbo either because no one was available to pick them up or their diagnosis was unknown.

Getting a 'day ahead' of illness

Data showing that roughly 85% of children who have a telehealth visit at school return to class is what appeals to educators, Martin said. “If we can help keep them at school and take away a reason for them to miss, that’s what principals like,” she said.

If a student needs a prescription, the provider typically calls it in to the pharmacy immediately instead of the parent making an extra stop, which usually means the student can get a “day ahead” of treating an illness, Garrett said.

Santos, in Planada, especially notices a drop in the number of days students are out because of head lice because the Hazel providers ensure treatment begins the same day. Chronic conditions such as asthma are also less likely to keep students out of school because the provider can prescribe an inhaler and make sure an action plan is on file. And if a student just kept winding up in the office with the same symptoms because something else was making him or her want to go home, the provider can figure that out.

“Hazel helps identify when a tummy ache may actually be the result of a classroom [or] friend issue, or an issue at home,” Santos said, “and we can resolve it.”

Also available for staff

Santos works part time and is, therefore, not at the schools every day. And in reality, many school nurses are spread among multiple schools and also responsible for other school-wide health-related efforts, such as vision and hearing screenings.

When nurses are not available for a telehealth visit, another school staff member is trained as a “presenter,” which Martin said boils down to knowing “how to shop on Amazon and turn on a digital camera.” The healthcare professional is the one directing the visit, while the presenter operates the digital stethoscope, otoscope or other instruments.

The telehealth providers also contact the child’s family physician if further follow up is needed. And if the child doesn’t have a “medical home” or the family doesn’t know that they were assigned one, the telehealth provider acts as that bridge, Golomb said. 

“With the nurses,” he said, “they are so stretched they can’t always be the ones to reach out into the community to make that happen.”

Increasingly, school staff members are also using the service, which keeps them from having to miss school for appointments as well. “Then the lightbulb comes on,” Martin said. “Then we see the numbers increase.”

Recommendations for leaders

Even with high “return-to-class” rates, Martin said there are still those who are skeptical about the model. She’s heard from community members and parents who want schools to “just teach my kids.”

One night at a high school football game when she was handing out brochures about the program, she also heard from a parent who said she didn’t want her daughter’s teacher knowing what was in the child’s medical record. That comment made Martin realize that privacy was a concern, but she explained that the extent of the information shared with teachers is that the child is allowed to be in class.

She added that school nurses are the ones who can get district leaders and teachers on board. “It takes going in and making relationships,” she said.

Martin also shared some recommendations for school and district leaders interested in adding a telehealth program. She doesn’t advise that districts purchase equipment first or apply for a grant to purchase equipment, and she added that she feels she plays a role in keeping school districts from getting “snowballed by a sales pitch.”

It’s better, she said, to use grant funds to conduct a community needs assessment to see where the gaps to healthcare exist, adding that if there’s a pediatrician nearby whose schedule is only half-full, then maybe the in-school program isn’t necessary.

As with any technology, equipment can also become quickly outdated. In MCS, telemedicine carts with computer monitors and keyboards have now been replaced with an iPad transported in a “soft-sided lunchbox,” Garrett said. “The technological advances are making something that we’ve made accessible even more accessible.”

He added that he didn’t want his schools to become dispensaries, so no medicines are kept on site. Money for patient copays or other charges also doesn’t change hands at the school. Providers will bill insurance or Medicaid just as they would in a doctor’s office, and the parent would receive a statement for the copay.

Combe with NASN advises that administrators make sure any agreement with a provider says the services are available “for any student on their campus versus only those that have a certain type of insurance.”

School telehealth costs vary depending on the model. Health-e-Schools, now in three North Carolina districts, is funded with grants, which is especially helpful with providing the services for free to students without coverage. “We want to take care of that uninsured kid that just got here from Guatemala, and they don’t trust anyone,” Martin said. Schools also provide IT support and space for the appointments.

With Hazel Health, the costs vary on a variety of factors. The company "works with each district closely to find pricing that is affordable, including grants," according to a spokesperson. "Also, as Hazel moves to a model where payers cover a significant portion of the costs, the fee will be significantly reduced." 

In Planada, the price comes to about $60 per student — or about $54,000 — which the district pays for out of its local allotment of state funds. The expectation, González said, is that in the long run, the district will recover the cost through average daily attendance funding because of fewer “prolonged absences.” 

In MCS, Garrett said there has been a significant increase in the number of students staying at school. “We know now that kids have a harder time faking it,” he said. “It’s taken a lot of guesswork out of who should be at school and who shouldn’t.”