Adapting to Ever-Changing Conditions: How Open Door transformed Virtual Care during the pandemic
In 2020, the COVID-19 pandemic forced School-Based Health Centers (SBHCs) to quickly pivot to telehealth in order to deliver care among school closures and ever changing COVID-19 guidelines and regulations. While some SBHCs had already begun utilizing telehealth, for others the transition was more abrupt and the NY School-Based Health Foundation (the Foundation) knew that SBHC staff had developed creative solutions to address barriers facing telehealth.
With the support of the Mother Cabrini Foundation, the Foundation offered our first ever Telehealth Story Contest to gather first-hand accounts from SBHC staff across the state with the hope that sharing their solutions would inspire others. This is the story of Open Door Family Medical Center’s SBHCs and how they addressed the barriers associated with telehealth. Special thank you to Director of SBHC Operations, Sara Hodgdon, for her story submission.
Early Pandemic Days: March 16, 2020 former Governor Andrew Cuomo announced that due to the emerging coronavirus outbreak, all New York State schools would close starting March 18th (1). At the time, schools were ordered to close for at least two weeks, after which Governor Cuomo would decide whether or not to extend remote learning.
After multiple extensions on the stay-at-home order, on May 1st, 2020 the Governor announced that schools would remain closed for the remainder of the academic year. Prior to this announcement, schools were to be closed only through May 15th.
Especially in those first few months of the pandemic, New York state was hit the hardest, and was the first to enact stay-at-home orders. This meant that for students and school staff, the transition to remote learning was the first attempt in the country at organizing a wide-scale virtual learning system.
For students who depended on their schools for social services such as meals, behavioral health care and primary care, the abrupt closure of schools meant access to these services halted. The school-based health team at Open Door Family Medical Center recognized the importance of programs to address emerging and chronic care needs for students stuck at home and responded by greatly expanding their telehealth program.
Open Door operates nine federally qualified school-based health centers across three school districts: Ossining, Port Chester, and Webutuck. Through their school health program, Open Door provides students with medical and dental care, as well as behavioral health screenings and referrals. Each SBHC provides a full range of accessible primary health care services to students of all ages in the school district, whether or not they attend the schools where the health centers are located. In total, around 5,000 children and youth in Westchester and Dutchess County are enrolled in Open Door’s school health program.
Attending to Students’ Growing Needs: As stated, in the first few months of the coronavirus pandemic in the U.S., New York was the first state to be impacted by stay-at-home orders and school closures. This was especially true in Westchester county where at the time, Open Door operated all their SBHCs.
According to testing data from New York state, on March 26th 2020 in Westchester county, 10 days after schools went remote, there were 128.5 positive cases of COVID-19 per 100k (2). Compared to the statewide average of 37.8 positive cases per 100k on the same day, Westchester was a region of the state hit particularly hard in the early days of the pandemic.
Since the onset of coronavirus in the U.S. in March 2020, Westchester county has documented 2,837 covid-related deaths at the time this article is published (3). For students residing in Westchester at the height of the pandemic, there was no doubt a lot of fear and uncertainty impacting their daily life, the consequences of which are still felt to this day.
The worsening mental health of students due to COVID-19 is not unique to Westchester or even New York state. In the United States, there are over 250,000 estimated children who have lost a parent or caregiver to the coronavirus (4). In an interview with the New Yorker, Dan Treglia, a social-science researcher at the University of Pennsylvania and a contributor to the Covid Collaborative, the number of covid-orphans is likely higher than currently estimated, “This is a problem in every state and every community, yet some groups have been hit harder. Black and Hispanic children lose caregivers at rates more than double those of white children.” (5).
These variations in the number of children who have lost a parent or caregiver are partly a matter of geography; states such as New York and California, which have significant minority populations, were both hit hard early in the pandemic, before treatment was possible.
For those working for the Open Door school health program, this time period was marked by a need for sick care for patients stuck at home, as well as for ongoing mental health and well care, especially for students with chronic conditions. Therefore, they began the process of setting up the proper infrastructure and training among staff to offer as wide an array of virtual services as possible, to ensure students were being evaluated and their growing needs attended to.
Expanding Telehealth and its Surprising Benefits: According to the Director of SBHC Operations at Open Door, Sara Hodgdon, in these first days of the pandemic, Open Door shut down their school health operations for about two weeks before reopening to offer in-person and virtual care. Initially, staff were faced with technical barriers, specifically access to adequate wifi and devices that could perform telehealth appointments.
Being as flexible as possible, Open Door offered remote services first as telephone sessions (audio-only) done oftentimes from providers personal devices. They were then able to switch to Doximity, a telehealth platform and online networking service for medical professionals. Doximity allows the Open Door team to keep all their telehealth related appointments in one platform while protecting the providers’ private contact information, no matter what device is being used.
An important step in the transition to Doximity was to train staff on its functions and set them up with the service, as well as ensure that every staff member had access to a device they were willing to use for appointments, as well as reliable internet connection.
According to Ms. Hodgdon, these barriers were addressed using financial support and expertise provided by the Foundation through our Telehealth Program. Funding from the Foundation was used to purchase new equipment for staff and the SBHC team at Open Door ensured that extensive coaching and support were given to all members of the team. This equipment included laptops, headsets, and a full computer set up with built-in cameras and microphones for the clinic spaces.
Once the infrastructure was set up to offer students services remotely, whether they were telephonic or televideo appointments, Open Door began the process of re-engaging students in their services. The team developed text campaigns, email messages, and notices sent directly from the schools to promote the availability of telehealth services while students were learning remotely.
To ensure that families were also made aware of the SBHC services, principles were key partners in engaging parents and caregivers. For the schools Open Door serves, principals notified all families that although schools were closed, the SBHCs would remain open and deliver care virtually.
Especially during these first few months of the pandemic, Ms. Hodgdon found the opportunity to connect with students in their homes to be especially beneficial in addressing wellness issues and supporting children who needed nutritional counseling, “Our youngest patients were excited to show us their refrigerators and cabinets and moms making dinner! We could talk with them specifically about food, choices, and quantity. No longer stuck in the abstract, children were able to show us their favorite snacks, and we could support them and help them think about all of the healthy food choices they could make and the fun they could have helping their parents plan and make snacks and meals.”
Beyond the benefits to nutritional counseling that telehealth yielded, there were also surprising advantages to delivering care to students who were home sick, the team could help these children and their caregivers consider the spaces in their homes and options for isolation. As Ms. Hodgdon reflects, she notes that these services not only benefited the patient who directly received them, but it gave the Open Door team a window into their families and offered staff an opportunity to address needs beyond the student, “We also found that we were able to intervene when a telehealth visit revealed that a family member of our patient was sick enough to require emergency care, and thanks to telehealth we were in a position to make that recommendation.”
Overcoming Barriers with Flexibility: Over time as COVID-19 restrictions began shifting, Open Door was able to offer services virtually and in-person when needed. Faced with ongoing staffing shortages, once students returned to in-person/hybrid learning in the 2020-21 school year, Open Door utilized telehealth to connect patients from the SBHC to providers based in community sites. These students were engaged through their SBHC primary care visits and their needs were assessed using screenings and topics brought up in conversation with the medical provider and support staff.
Due to the national workforce shortage of medical providers, many health organizations have dealt with limitations on their delivery of in-person care, and the Open Door SBHC team was no exception. Therefore, Ms. Hodgdon describes the value they saw in offering virtual care as a triage method, to meet with a patient remotely and gauge if it was necessary that they be seen in-person by a provider.
Their solution was to turn one exam room into a virtual care room, using the equipment purchased through Foundation funding. Students could come to the clinic in their schools and meet with a provider who was working remotely from another site, while support staff assisted and performed assessments. This also allowed the physician on site to take care of acute illnesses or emerging injuries that were common in those first few months back to in-person learning.
Beyond just the clinic and its staff, having an option to meet remotely with a provider using SBHC equipment was especially helpful for students who did not have adequate access to wifi and technology at home. And for those students who take their appointments from home, Open Door continues to offer flexibility with patients by allowing audio-only sessions whenever needed.
As Ms. Hodgdon reflects back to the first semester, she recalls the challenges and struggles students faced as they adapted to in-person learning, “Fall 2021 was a tough time. There were many mental health crises in the schools and medical emergencies, too. There was just so much trauma. A lot of really ill adults and young kids taking care of their parents who weren’t able to take care of themselves, while also trying to connect to remote learning. Students made it through this period, and then they’re suddenly back sitting at a desk.”
The abrupt transition from pandemic schooling to in-person learning was tough on students who had faced so much fear and uncertainty in the year prior. And Open Door found telehealth to be an excellent, flexible tool to provide students with access to care.
The Takeaway: Open Door’s experience in using telehealth at all different stages of the COVID-19 pandemic has shed light on the importance of flexibility, adaptability, and creativity when delivering care in a school setting. At each step of the process, the SBHC team at Open Door had to consider not only what was feasible due to pandemic constraints, but also what was necessary to ensure students remained in care.
While faced with initial technical challenges, Ms. Hodgdon reflects on the surprising benefits of telehealth in giving providers a window into their patients’ daily home life. And while telehealth certainly was useful for services such as nutritional counseling and behavioral health, the Open Door team still managed to find its benefits when delivering primary care. As a creative solution to staffing problems, the SBHC team at Open Door leaned on the resources they did have, mainly telehealth equipment, in order to ease staff shortages while allowing students to be seen by a provider when needed.
Ultimately, between March 2020 and May 2022, Open Door completed 5679 telehealth visits and counting. When asked how they plan to continue using telehealth, Ms. Hodgdon said they plan to continue using telehealth to reach SBHC patients, and to ease the strains on the school-based health care system by offering providers more flexibility in seeing patients. As a result, Open Door hopes to continue being a space for students to turn to, whether that be in-person or virtually.
Check back here for future telehealth stories from contest winners!