Bridging the Digital Divide: How Northwell's SBHCs Expanded Access to Telehealth for Students

In 2020, the COVID 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 CCMC/Northwell Health’s SBHCs and how they addressed accessibility and privacy for the students using their telehealth services, as told by Mental Health Program Coordinator, Annemarie Goodman.

*To protect patient confidentiality, the students’ identifying information has been changed.

Case-study on Telehealth Usage: Although classes have mostly resumed in-person this past school year, the traumas that arose out of the first year of the pandemic remain a large struggle for many students working to adjust to our “new normal.” In the case of one high schooler, Gabriel*, returning to in-person classes presented with many challenges not only for himself, but for his family as well.

Gabriel and his family had immigrated to New York in the midst of the pandemic and he presented with multiple social-emotional, medical and mental health needs to the Northwell Health’s SBHC. His mental health issues made it impossible for him to attend classes in-person once they resumed in the 2021-22 school year. Not only did Gabriel need support, but his family also was in need of much psycho-education around depression, the impact of bullying, guidance around how best to support their son and assistance in navigating multiple systems.

To meet his complex needs, a SBHC Nurse Practitioner and Clinical Social Worker worked together closely with Gabriel throughout the year using telehealth. At first he was reluctant to even meet with the therapist and never showed his face. However, over time, as trust was developed and small improvements made, he started turning his video on more often for at least part of the session.

As one would expect, his progress was slow and not without many hurdles, and during times of crisis, the clinicians were able to better assess over telehealth platforms and connect the student and his family with various outside resources. This past spring with much support, Gabriel has been able to make it through several days of in-person classes, due in great part to his ability to access Northwell’s telemental health services and work with his family through his struggles.

While Gabriel’s case is just one example of how telehealth has been utilized, his story demonstrates that although school has largely transitioned from online to in-person, telehealth has still proven its value. These telehealth sessions acted as a lifeline for many students for whom time with their therapists was their only connection with someone outside their family and to receive mental health support.

Other stories in this series of contest winners will demonstrate a wide variety of additional benefits of telehealth, whether school buildings are closed or open, including its use to optimize scarce staff resources, connect students to specialty care, facilitate chronic disease management and even conduct routine preventive primary care. This story in particular focuses on how Northwell Health acted to make telehealth more accessible to their students.

Northwell Health operates five school-based health center campuses which serve 20 individual middle and high schools in Queens and Brooklyn. For many students in these communities who would benefit most from telehealth, it can be a challenge to access these services due to limited family income and the economic hardships brought on by the pandemic.

The Digital Divide Facing Students: While telehealth has proven to be an incredibly powerful tool in expanding healthcare, particularly during the pandemic, those who have difficulty accessing technological devices or the Internet can be at an extreme disadvantage. For many individuals living below the poverty line or on a fixed income, there is a significant “digital divide” because their financial situation does not allow them to afford new devices or even consistent Internet access.

In a 2021 Survey released by the AMA, physicians identify limited access to technology as the biggest barrier to patient care, followed by limited digital literacy and limited patient access to broadband internet.

In their switch to telehealth at the start of the COVID-19 pandemic, the SBHC team at Northwell Health discussed the barriers to care they were witnessing and brainstormed how they could address these while meeting the growing needs of their students.

According to Mental Health Program Coordinator, Annemarie Goodman, many students were opting for telephone sessions (audio-only) because they afforded privacy and did not require access to additional devices and reliable internet connection. A goal of Northwell’s telehealth program was to transition clients who had previously been more comfortable with audio-only sessions, to audio-video sessions which are richer therapeutically. Audio-video sessions are also more financially sustainable as they can be billed at a higher rate than audio-only sessions.

Expanding Access to Telehealth Services: Utilizing grant money from the Foundation’s Telehealth Program, Northwell Health purchased cordless headsets, I-Pads and internet hotspots to share with students in order to increase accessibility and privacy for those accessing telehealth services. Ms. Goodman explained that many of their students were sharing devices with siblings, had limited wifi services, encountered issues at home finding privacy, or like Gabriel, experienced anxiety which made it challenging for them to log in for sessions.

The equipment Northwell purchased was distributed amongst the five SBHC campuses to be loaned out to students in need. Each device was labeled and the SBHC team at Northwell implemented a system for tracking who received equipment. The devices could also be lent out to families to facilitate virtual psychiatry sessions with both parent and client.

To determine which students would benefit from receiving a loaner device, the Northwell mental health clinicians were able to ascertain which students in their caseloads might be experiencing a barrier to connecting. They were also able to identify additional candidates for loaner equipment from their numerous referral sources such as school guidance and administration, word of mouth from peers and Northwell’s school-based health medical teams.

For outreach to the broader school communities, different methods were used to engage as many students and stakeholders as possible. Letters were sent to school principals, meetings were held weekly with guidance staff and key players to learn of the most at-risk students, and videos were uploaded to school websites introducing the SBHC staff for each campus, outlining Northwell’s services and how students could connect with a health professional virtually. Individual clinicians were also tasked with informing all students on their caseloads about the equipment purchased through this project, especially when they encountered a student in need.

In doing so, the Northwell SBHC team was able to transition many students who had previously been engaging in telephonic sessions to telehealth video sessions. However, the program did not come without its challenges and changes along the way. These forced the team to continue adapting to the changing pandemic health landscape, and find ways to continue making the program available and accessible to students.

Adapting to Changes: After deciding to purchase equipment to loan to students, the SBHC team at Northwell faced numerous roadblocks in getting the program up and running. The first challenge was gaining approval from the larger Northwell hospital system to distribute devices where students could have access to the Internet and websites beyond the telehealth program.

This required many conversations with hospital administration and the IT support team to find a solution. After much research on the best devices/tablets to utilize, the SBHC team was able to purchase I-Pads, and each I-Pad was set up with restrictions limiting students access to only the telehealth program they were installing.

While this project was conceptualized and initiated during the 2020-2021 school year in which remote and hybrid learning was the norm, the slow approval process meant that by the time they were actually able to start the program, the team learned that school would be returning to all in-person learning beginning in September 2021.

While the staff had been able to transition students from telephonic to televideo sessions, the change to in-person learning meant that now, a majority of their therapy appointments would switch from telehealth to in-person sessions. However, as Ms. Goodman notes, this did not render their program obsolete, as exhibited through Gabriel’s experience, telehealth was still an important tool even as schools resumed in person learning.

When asked if Northwell’s SBHCs plan to continue expanding their program, Ms. Goodman expressed the consensus of the team this way: “Telehealth will continue to remain as an aspect of our programs services and enhance the in-person work, whether it be for crisis, sessions during school breaks or summers, to engage parents via PTA meetings or workshops on various topics, for collateral sessions or medication management and psychiatric evaluations.”

The Takeaway: In the aftermath of the pandemic, clinicians across the country have seen a sharp increase in students such as Gabriel with severe anxiety and complex trauma who are unable to attend school regularly or even at all. These young people and their families have complex mental health needs and are in need of much support to help them access mental health, medical and community resources. Telehealth has been vital in reaching these families and ensuring that care is continuous for students who are struggling with returning to school in-person.

Although the equipment they purchased was not utilized as completely as they had hoped during the grant period, due to multiple challenges in getting the devices approved and operating, the Northwell SBHC team is excited to now have them and plans to utilize their equipment to engage teens and families who may have not had access prior. For students like Gabriel and many others, being able to borrow an iPad, headphones, and Internet hotspots will make a world of difference in their medical and mental health care.

---

Check back here for future telehealth stories from contest winners!