School-Based Telehealth Implementation

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This report thoroughly captures all of the necessary components of a successful school-based telehealth program, especially the need to ensure that these programs are adjunct to a larger comprehensive system of care. This is critical to addressing the complex medical, social and mental health needs of children and adolescents throughout the state of Georgia.
Veda Johnson, MDExecutive Director, PARTNERS for Equity in Child and Adolescent Health

More than 170,000 of Georgia’s 1.8 million school-age children stay home sick from school more than six days a year. Absenteeism has a direct impact on academic achievement, including reading below grade level and increased probability of becoming a high school dropout. And that impact is heightened after six days. The top two leading causes of student absence are health related. While illness is not the only reason that children may miss school, increasing a school’s ability to address health concerns holds promise as it relates to reducing student absences and improving academic performance.

The use of telehealth to increase children and families’ access to health care is a growing practice in Georgia. Within the last five years, school-based telehealth (SBTH) programs began emerging as a valuable tool for providing children primary, acute, and specialty care. While telehealth adoption has increased, several entities, including schools, have experienced barriers to implementation and utilization.

To identify the key components of successful SBTH programs, barriers to implementation, and the practices that address the barriers to success, Voices for Georgia’s Children (Voices) conducted a literature review and a case study of two different SBTH models in Georgia — a rural school-based health center (SBHC) program in North Georgia and a school nurse-based program in an Atlanta-area school. The rural site partnered with a regional federally qualified health center (FQHC), while the Atlanta-area site partnered with a local children’s health care provider.

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School-Based Health and Telehealth Amid the COVID-19 Pandemic

When Voices embarked on a SBTH literature review and case study of two different SBTH models in Georgia, we had no idea the COVID-19 pandemic was on the horizon. Now, as COVID-19 negatively impacts our nation, states, and communities, it may also serve as a catalyst for the implementation or renewal of SBTH programs. We hope interested schools, providers, philanthropists, and policy makers are able to utilize this report now, in our current context, as well as in the future, as a resource to move forward successful SBTH implementation in Georgia. Our children and families are depending on it.

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Key Findings in Our Report

Our findings indicate that the following capacities and resources are needed for a successful SBTH program:

Stakeholder engagement — support and buy-in from key stakeholders including parents and school personnel such as principals, nurses, and teachers
Technical capacity — equipment, internet access, training, and technical support
Human resources and administrative capacity — private space to render services, partnership with health care provider, communication with primary care providers/children’s medical home, and personnel to serve as presenter and to administer and manage program
Financial capacity — funding for operational costs, agreement with agency to handle billing

Equipped with these capacities and resources, schools are best positioned to successfully implement an SBTH program. However, despite best efforts, some schools and school districts may face barriers. Common barriers identified include:

Lack of stakeholder understanding of telehealth and buy-in
Difficulty engaging and sustaining relationships with health care providers or specialists
Low program enrollment
Underutilized equipment
Lack of adequate personnel to implement and manage the program
Lack of continuity in care (or care fragmentation)
Lack of quality benchmarks

Additionally, findings revealed that while a school nurse–based model can be effective, it can be more challenging to implement and sustain. When resources allow, the ideal SBTH program would be based within an SBHC. Most SBHCs have established partnerships with an FQHC or local hospital, ensuring access to primary and specialty care providers. Further, housing an SBTH program within an SBHC provides an infrastructure to provide comprehensive care and promotes sustainability, as partnering entities are eligible for more funding opportunities than stand-alone SBTH programs.

If there are limited resources, prohibiting the development of an SBTH program within an SBHC, findings suggest designing the SBTH program around the most common health concerns and either engaging the local primary care provider that serves the majority of the students or the local hospital/FQHC, as the distant site.

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Key Recommendations in Our Report

Information gathered during this process elicited several aspects of successful SBTH programs and strategies that schools can use to overcome potential barriers. Voices recommends implementing the following strategies to increase the possibility of SBTHs’ positive impact on access and health.

Recommendations for Schools and School Districts

If possible, develop an SBTH program within an existing or planned SBHC. If this is not possible, foster strategic partnerships with local hospitals, provider networks, practitioners, or university systems to ensure access to providers and specialists.
Engage and enlist the support of key stakeholders before planning begins, such as district and school-level administrators, school nursing and office staff, teachers, parents, local health providers, and other community members.
Allocate time and resources to continuously market the program and recruit and enroll students.
Ensure an adequate number of trained personnel to provide services and the manage program’s administrative components, including billing/reimbursement and maintaining regular communication with primary care providers to ensure continuity of care (e.g., one trained presenter and two to three staff persons to carry out administrative responsibilities).
Ensure that all children, regardless of insurance status, are served through the SBTH program

Recommendations for Policymakers

Establish a governing entity (e.g., South Carolina Telehealth Alliance) for telehealth delivery that has authority to ensure quality, streamline school access to qualified telehealth providers and develop and encourage best practices.
Increase opportunities for telehealth programs to be implemented within a comprehensive health system (e.g., expansion of FQHCs, additional support for rural hospital-school partnerships).
(Medicaid) Expand health care locations able to conduct presumptive eligibility to include SBHCs or SBTH programs.

While programs have been effective in developing strategies to overcome common barriers, it is vital that key stakeholders identify and seize opportunities to make it easier to implement successful SBTH programs. The proposed recommendations offer strategic practice and policy considerations that can greatly reduce barriers to program implementation. The implementation of successful SBTH programs can significantly improve equity in access and health outcomes for Georgia’s children and families.

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