School-Based Telehealth Expands In North Carolina
In a small room at Hillcrest Elementary School in Burlington, students can now meet with a doctor during the school day — virtually.
The school joins a growing network across North Carolina where students don’t have to leave school to be seen for physical or behavioral health needs.
Health advocates say that school-based telehealth care cuts down on absenteeism, ensures that students receive routine care that they might not otherwise be able to get, and can even boost test scores.
At Hillcrest Elementary, one student’s recent visit for a stomach ache turned out to be an underlying dental issue — an abscessed tooth.
“They could have been out of school for two or three weeks, but we were able to figure out what was wrong and get him the proper care,” said Kristy Davis, chief student services officer for Alamance-Burlington School System.
Enhancing access
The COVID-19 pandemic “propelled the adoption of telehealth in school settings,” according to the authors of a 2023 review of more than 30 studies on school-based telehealth.
“The perceived benefits derived from these interventions were substantial, augmenting traditional approaches, enhancing clinical care, and fostering collaborative efforts within families,” the authors wrote. “The implications underscored the enhancement of healthcare access, early anomaly detection, and the elevation of nursing leadership within the telehealth domain.”
Yet telehealth services in North Carolina schools came long before the COVID-19 pandemic, driven in large part by difficulties in accessing care in far-flung rural communities.
In North Carolina, Health-e-Schools began providing telehealth services to schoolsin the western part of the state in 2011. The program, an initiative of the Center for Rural Health Innovation, started with a handful of schools in two districts. Today, it serves more than 90 schools in seven western North Carolina counties and partners with 40 schools in four southeast counties.
In Guilford County, Cone Health launched its first telehealth clinic in 2021 at Bessemer Elementary in Greensboro through a partnership with Guilford County Schools and the Guilford Education Alliance. By spring of 2024, 14 low-income schools in the district were participating. Another 12 schools have been added this academic year.
In fall 2024, Cone added Moss Street Elementary in Rockingham County Schools, followed by Hillcrest Elementary in the Alamance-Burlington School System earlier this year.
Davis is already eyeing expansion in Alamance-Burlington.
“It is something that we want to put in more schools,” she said.
Working together
The Carolina School-Based Telehealth Learning Collaborative, which includes the western North Carolina and Cone Health programs, held its spring meeting in Greensboro on April 4.
About 50 people, including several virtual participants, gathered at Union Square Campus to talk about growing school-based telehealth programs. The collaborative is made up of 17 partners — hospital systems, university programs and health agencies — from North Carolina, South Carolina and Virginia.
They shared what’s working or not working, and what they have coming up.
The programs use different models to provide care.
Cone Health uses a certified medical assistant as a “telepresenter” who is based in the school. Their program also involves parents in the visit, usually by sending them a link to their smartphone so they can participate.
The medical assistant/telepresenter gets about four weeks of additional training. They work full time, so they can act as a part of the school health team, said John Jenkins, medical director of Cone Health School-Based Care.
Families must sign a consent form before students can be seen at the clinic. A provider, such as a pediatric nurse practitioner or a pediatrician, gets pulled in for cases such as an earache, upset stomach, injuries and colds, for example.
That provider can assess the child using special equipment handled by the certified medical assistant, “just as if they were in their own office,” Jenkins said. The Bluetooth-powered equipment allows the remote provider to visualize the ears, throat, heart and lungs of the patient and send a prescription to the pharmacy, if necessary. There are also some medications in the clinic that can be sent home with the child if prescribed.
“The vast majority, about 90 percent of the time, we would return children to class the same day,” Jenkins said.
In Guilford County Schools, 42% of students at the schools with clinics signed consent forms to participate, district data shows. That year, there were 3,174 clinic visits, which led to 1,440 virtual telehealth visits with a doctor or nurse practitioner.
Guilford County Schools officials have seen improved attendance at all of the participating schools, according to data shared at the telehealth conference. Two-thirds of the schools experienced a decrease in office discipline referrals on average for students participating in the clinic compared with those who were not. In addition, students who signed up for the clinics at many of the schools did better on end-of-grade reading and math tests than their peers.
‘Showing improvement’
The latest area of growth for the school-based telehealth collaborative has been in telepsychiatry for behavioral health issues.
The Improving Adolescent Child health Through Telepsychiatry in NC has been providing therapy and psychiatry telehealth care in schools for about two years. The program operates out of the Department of Psychiatry in the School of Medicine at UNC Chapel Hill.
Early data shows that 70 percent of patients reported improvement with depression, 86 percent improvement for anxiety issues and 69% improvement for children with attention deficit hyperactivity disorder, said Charissa Gray, program director of virtual care and integrated behavioral health at UNC Chapel Hill.
“Definitely people are showing improvement, so we want to continue to see these numbers grow,” she said.
Their program is continuing to evolve.
They’ve looked at enhancements such as rotating session times so a student isn’t missing the same class each week, or having someone available to speak Spanish, said Stephanie Brennan, a pediatrician and child and adolescent psychiatrist who works with the UNC Chapel Hill program.
They’ve also been flexible with who helps the student connect to the session. In some schools, that’s the school nurse or school social worker. In others, they give the school the money to hire a contractor to be there.
“And that’s been really working out beautifully. That person is part of the school culture,” said Alison Burke, a clinical instructor with the program. “They also make sure the technology is working well. And they’re also there outside the door in case we need them, in case there’s a crisis or anything like that.”
Charlotte-based Atrium Health also recently added school-based telepsychiatry, which is now available in 57 schools throughout the southern Piedmont.
A real “pain point” has been juggling the various schedules for schools, including early release days and teacher work days and other days off, said Donnie Mitchem, director of Atrium Health’s Behavioral Health School-Based Teletherapy.
She said in some participating schools the Atrium program will only see the commercial payers because they have somebody in house who sees Medicaid patients. In some schools, it’s the opposite.
Cone Health is in the process of adding behavioral health to its school-based telehealth clinics. They’ll pilot the program in a few schools first before expanding it, Jenkins said.
Community care
At the Greensboro conference, the keynote speaker encouraged members of the school-based telehealth collaborative to expand telehealth to the community.
Schools are often natural gathering places for communities, they have spaces to allow for private conversations, and they have the reliable technology access that many homes may not have, said Kathy Wibberly, director of the Mid-Atlantic Telehealth Resource Center. The federally funded center serves North Carolina, seven other states and the District of Columbia.
Expanding telehealth services to the community could include everything from helping families deal with nutrition education or mental health issues or abuse issues that are going on in the home, she said.
“Because if the students are healthy, but the family is unhealthy, the students aren’t going to stay healthy for very long,” Wibberly said.
Several of the North Carolina collaborative members said they are already expanding their services.
The UNC Chapel Hill telepsychiatry program will be offering therapy over the summer to school staff.
Jenkins said Cone Health’s program plans to partner with the hospital system’s virtual urgent care program to give teachers an opportunity to be treated while at school, so they don’t have to leave for routine issues.
Davis, a former teacher, knows how beneficial that will be.
“That teacher that takes a half a day to go get their blood pressure checked, that’s a lot of instructional time missed as well,” she said. “If it’s something that they can go get it checked by the telehealth presenter and stay at work and just be gone for 10 minutes, that’s a win … for everyone.”