School-Based Healthcare Moves Virtual During COVID-19

By Karen Kaighan and Jason Isham

As schools face heart-wrenching decisions around how to educate kids during the COVID-19 health crisis while keeping students and staff safe, school nurses are perhaps feeling the most strain.

These days, school nurses are often responsible for assessing children and faculty presenting with COVID-19 symptoms. And with the health crisis putting a pause on access to some regular healthcare services, many children are not getting the care they need. This puts an even bigger responsibility on school nurses, some of whom were busier than ever when schools shut down last spring.

Telehealth increasingly is helping school nurses meet students’ physical and mental health needs, both in school and virtually—and lawmakers are recognizing its importance. At Children’s Health in Dallas, our partnership with over 225 schools across the Dallas metro area provides vital access to specialty support for children and teens and guidance around infection control.

A back-to-school approach to telehealth

Even before COVID-19 was a blip on the radar screen, we saw the benefits of using telehealth in school settings. In 2014, the health system began partnering with schools to bring virtual primary and specialty care into the building, such as by providing one-on-one virtual education and support for asthma management. The impact: 72% of parents whose children have relied on our school-based telehealth services say the initiative helped their children avoid an emergency department visit.

However, when COVID-19 struck, we quickly realized that a broader virtual approach would be critical.

In mid-March, when schools closed their doors to in-person learning, our technology team brought school-based telehealth equipment and devices back into the hospital, where they could be sanitized and used. Team members provided urgent care and behavioral health services virtually for students who ordinarily received these services in a school environment. Staff also offered free assessments of COVID-19 symptoms in students via telehealth and directed students to in-person treatment, where needed. From March through September, we recorded a 500% increase in telehealth urgent care visits among students compared with the same period in 2019. As school start dates approached, the health system distributed 150,000 masks to students to help limit exposure to the virus.

Then, as the 2020–2021 school year approached, we partnered with school nurses to ensure children and faculty were kept safe as they returned to the classroom. We started by launching a “Back-to-School COVID Conference,” bringing together more than 900 school nurses throughout the Dallas metro area to discuss what school-based care delivery should look like during a pandemic and how nurses could most effectively protect themselves. Collaborating with UT Southwestern, we shared best practices that would help ensure nurses felt comfortable providing complex as well as routine care. We also supported school nurses by providing fit testing for them as well as for essential school and college personnel. And we offered school districts a daily quick-screen COVID-19 symptom checker for staff, student, and teachers before entering school.

Education was a key pillar of our strategy, thus we also expanded on our programming for Children’s Health℠ LIVE, an accredited, web-based continuing education series. Our “The Nurse Is In” and “Teacher Talk” series give nurses and school staff the clinical educational support they need to provide care in school. While we originally kicked off the program in 2015, we knew we had to keep creating new education to help bridge the gap between the presentation of symptoms, diagnosis, and referral.

Team members coached nurses on how to provide virtual care, as many school nurses were doing so for the first time. The team also supplied devices that could work in tandem with the telehealth platform, such as a digital otoscope that sends virtual images of the inside of a child’s ears to an online physician or a scope that captures images of a child’s throat. These devices will be particularly important as cold and flu season ramps up, as they can help nurses evaluate children who present with ear, nose, and throat complaints.

Our health system also reached out to parents to help guide them in the decision to send children with a medical condition back to an in-person school setting. By examining the health history of high-risk kids and teens, physicians and nurses could provide the right guidance for families on whether face-to-face instruction or e-learning would best meet a child’s needs.

To maintain continuity in care for in-person and e-learning students alike, our “School Telehealth at Home” program provides families with in-home school telehealth support. By downloading the Children’s Health Virtual Visit app, parents can schedule a virtual health visit for their children. The health system also offers a 24-hour nurse hotline that families can call for answers to health questions.

Behavioral health services

The need for school-based behavioral health services rapidly expanded during the pandemic as children and families increasingly struggled with mental health. In fact, a study from the American Academy of Pediatrics found that one in seven parents reported worsening behavioral health for their children since coronavirus began to spread in March.

We have long offered behavioral health services virtually in school settings, such as our Teen Recovery Program, which assists students who are recovering from substance use disorder or facing mental health challenges. Because school-based telebehavioral services could easily be conducted in home settings, team members were able to continue offering virtual behavioral health support to students while schools were closed. Through June 2020, our health system conducted 963 telebehavioral health visits with students in the Dallas area, ensuring continuity in care for students in need.

During the 2020–2021 school year, we will offer both school-based and at-home telebehavioral health services to eliminate gaps in care for vulnerable populations. Families can access a behavioral health provider by scheduling an appointment via the Children’s Health app. When prescriptions are needed, our team works directly with parents to meet the child’s needs and provide assistance around medication adherence.

The program has demonstrated strong results among Dallas-area students. Children and teens experience a 32% improvement in their clinical goals for treatment based on self-ratings conducted before and during treatment. As the program continues to expand during the pandemic, we will offer telebehavioral health in nearly 180 campuses this fall, with continued availability in students’ homes as well.

Measuring the impact

Today, school-based telehealth is our fastest-growing telehealth program—and it continues to expand. Since January 1, we have conducted more than 14,000 telehealth encounters with children and teens—from rapid strep and flu testing to asthma treatment, behavioral health, and sports medicine. We worked with 93 schools in 2018, then grew to partner with 145 schools in 23 school districts across the Dallas metro area in 2019. Currently, for 2020, we’re working with over 225 schools in 27 districts. That’s a 64% increase since 2018, demonstrating the rising need for telehealth support for schools and students during the pandemic.

Our efforts at Children’s Health in Dallas point to some important lessons learned:

Work with school nurses in building out your organization’s telehealth platform. These professionals’ familiarity with families in your community can point to the services that are needed most, giving you the insight to develop a high-value approach. Our experience with schools in the Dallas metro area indicates that some schools had been looking for a health system partner; however, they could not find a healthcare provider willing to take the leap.

Focus on continuity in care. Establish a dedicated panel of providers to supply telehealth services for e-learners and in-person students, and ensure that follow-up visits can be performed in the same setting as the initial visit, where possible. Provide a hotline for students and their families to ask questions about their medications or care after hours, and enable parents to contact providers directly, if needed.

Make sure your telehealth workflow model matches that of the school-based offering. For instance, the way in which students and families connect with your telehealth team during school hours should match the process for receiving support after hours.

By collaborating with school health professionals to design the right platform of services and approach, healthcare providers can help ensure children receive the right care in the right setting during COVID-19 and beyond.

Karen Kaighan is director of school health programs and Jason Isham is director of integrated behavioral healthcare at Children’s Health in Dallas.