In its sixth year of providing school-based care via telehealth in four counties of North Carolina, the nonprofit Center for Rural Health Innovation’s Health-e-Schools program has grown into a national model. What started as a pilot in three rural schools in the Appalachian Mountains has grown to 33 schools in four counties.
The program’s founder and medical director, Steve North, M.D., made the transition from schoolteacher to primary care physician to telehealth program executive. Here is his story: In the 1990s North was a Teach for America corps member in rural North Carolina. He remembers seeing a student who had come to school after stepping on a nail. He couldn’t concentrate on his schoolwork, and the parents had trouble getting him to a provider because they had one car and both worked two jobs. At about the same time he read a book by Joy Dryfoos called “Full Service Schools,” about the idea of school-based healthcare.
“It just made sense to me that we should be providing care to kids where they spend the majority of their days,” he said. Later he went to medical school at the University of North Carolina and then did a family medicine residency and an adolescent medicine fellowship at the University of Rochester, with a focus on school-based healthcare. It was there in 2005 that he met providers who were working on school-based telehealth programs, a concept he took back to rural western North Carolina.
Even though they had grant funding, starting up a telehealth program was full of challenges for North and his colleague Amanda Martin, the executive director.
“School-based health centers were not known in our region. We were looking at providing care at a new place and by new means,” North said. “When I started shopping this idea around to the school systems in 2009, no one had really heard of telehealth.” He said one preliminary issue was the technology. “We got our first three carts but they were put together by a videoconferencing company that didn’t really know telehealth. In our next rollout we went to a specifically designed telehealth cart.”
Another challenge was that the program relies on school nurses who present the patients to providers. “Without their support we wouldn’t see any kids. They are our eyes and ears in the school,” North said. “In our first three schools, two of the nurses were not enthusiastic about the program. Because we didn’t have buy-in from them, it was a challenge. But we now have three excellent nurses in that district, and they are our busiest of our three districts.” He said maintaining good relationships with those school nurses and supporting them is key. “It doesn’t always have to be a telehealth visit, but if they are trying to figure out a new way to improve care for kids with allergic reactions, they often call me or one of our other providers to talk it through.”
In the first few years, they didn’t have funding for a full-time provider and that resulted in slower uptake. “Once we were able to have a full-time provider, that was a huge benefit for us. We have two nurse practitioners who job-share.
“We have a centralized scheduling person and an e-mail address. We have found that is the best way for nurses to contact us. A parent or the nurse can e-mail and set up an appointment.” North does a lot of behavioral health work such as medication management for ADHD. “Those are typically scheduled appointments. The rashes, coughs and colds, UTIs, strep throat, those are more on-demand. Depending on the season, we can see 14 patients in a day or we can see none. That is the hit-or-miss nature of what we do.”
At first they only had a pediatric nurse practitioner. Once they started seeing teachers with a family nurse practitioner, uptake really improved. “Now the teachers could be seen as well as part of a workplace health offering. That in turn makes them advocates for the program.”
The program bills and gets reimbursed by private insurance companies and by Medicaid in North Carolina.
It requires parental consent, and students are enrolled at the beginning of the year, or on demand. “We use Athenahealth as our EHR and send records over to the primary care provider after we see the patient," North said. "That is one of the areas that has been slowly growing — working with the students' regular providers.”
North mentioned several ways the program is currently expanding or plans to. “This year we have partnered with Mission Children’s Hospital in Asheville, working with the pediatric pulmonologist and asthma educator. We have rolled out a comprehensive asthma management program focused on education and on how to treat an acute asthma exacerbation at school,” he explained. “At what point does the nurse does engage the telehealth providers or the child needs to go to the emergency room? We are making sure there is a rescue inhaler at school and at home.”
The center also wants to establish partnerships with ACOs. “When we see a child via telehealth, the quality indicators get sent to their primary care provider’s EHR, and they get credit for that — and they can refer out to us. It would be great if that provider could say to a patient, ‘I would like you to be seen by the nurse practitioner through Health-e-Schools and she will report back to me on how you are doing.’”
The program also partners with the statewide Community Care of North Carolina, which offers enhanced case management. “We partner with them to identify at-risk children and high emergency room utilizers, especially for things like asthma, and try to get them into more regular care and on more appropriate medications.”
As far as expansion goes, North said, they are already talking to six schools in an adjacent county in Appalachia. But in other areas of the state, he suggested that it might be better for local groups to actually build and run the programs with consultation from the center.
Last year the federal Health Resources & Services Administration awarded a series of telehealth grant focused on school-based telehealth. North and Martin, who are on the board of the Mid-Atlantic Telehealth Resource Center, are consulting with many of the groups that got funded.