In 2021, the COVID pandemic forced School-Based Health Centers (SBHCs) to quickly pivot to telehealth and to address skyrocketing behavioral health needs. The transition was hasty and the NY School-Based Health Foundation knew that SBHCs would need integrated, HIPAA compliant, reimbursable systems in the long run. With the support of the Mother Cabrini Foundation, the Foundation offered a technical assistance program to strengthen SBHC telehealth services. Many creative efforts emerged. This is the story of the University of Rochester School of Nursing’s (UR SON’s) two SBHCs and the creativity with which they chose to address their students’ burgeoning behavioral health needs as told by SBHC Director, Nichole Gardea. Butler (MS, LCSW-R) to Sarah Bacio, the Foundation’s Social Media and Engagement consultant.
Background: The University of Rochester School of Nursing (UR SON) SBHCs provide free and comprehensive physical and behavioral health services to two schools in Rochester, New York. Together, they provide over 4,000 visits each year to 6th through 12th graders who receive care, regardless of their ability to pay or health insurance status. To address coronavirus constraints, UR SON implemented telehealth, in addition to in-person visits. Recognizing how crucial adolescence is for developing the cornerstones of not just physical health, but social and emotional well-being, UR SON provides education and support for healthy choices, developing coping skills, and problem solving, along with focused treatment and interventions for anxiety, depression, PTSD, and increasing resilience.
Burgeoning Behavioral Health Arising from the Pandemic: After the first few months, the toll the coronavirus was taking on students and school systems became evident. Teachers and administrators continued to refer students, over the summer months, making obvious the need for a broader solution. This is when UR SON discovered the “Fabulous app."
Finding a Solution: Developed at Duke University, the Fabulous app uses behavioral science to help its users develop healthier habits – mentally, emotionally & physically, including mindfulness & meditation. The app allows them to identify healthy behaviors and make decisions mindfully and with intention, rather than attempting to specifically address issues of depression or anxiety, with the goal of building long term resilience and coping mechanisms.
Student engagement is always an issue. So how did UR SON do it? Staff wisely engaged students from the very inception, first by asking a group of students to review several apps. They were unanimous in choosing the Fabulous app, because it broadly covered health and wellness and didn’t focus solely on mental health interventions or treating symptoms. Then, in a negotiation, Fabulous offered UR SON a discount and UR SON SBHC acquired 2000 licenses to the app with the assistance of the NY School-Based Health Foundation’s Telehealth Program.
Implementing the Solution: To engage students, staff started with students already enrolled in the schools’ SBHCs, offering them free subscriptions to the Fabulous app. The original plan was for SBHC providers to work with students during their regular appointments, but then they discovered that school does not allow student access to their cell phones during the school day. To overcome this, a student voice commitee hosted a special mental health afternoon, including a dedicated class period with teachers to access their cell phones to review the Fabulous app and download it.
In collaboration with the school social worker (in addition to community providers with a focus on mindfulness and healthy mindset), the UR SON team identified students to become Fabulous App ambassadors. Going further, they were able to offer students a small stipend to attend a one-day retreat to explore uses for the Fabulous app in their schools. The retreat allowed dedicated space and time to focus on self-care, mindfulness, and mindset. Overall, it was a huge success, allowing students the opportunity to work on leadership and social skills. Particularly notable was that students who had previously been unable to spend time together in the same space learned to work together in learning about the Fabulous app and brainstorming how to encourage adoption by other students.
In addition to the retreat, SBHC Director, Ms. Gardea Butler and others created a “closed” challenge for students at the school who participated with the app to help motivate them to engage in healthier behaviors around mindfulness, routine, and meditation. Examples of the challenges included students getting to school on time and getting more than 7 hours of sleep per night. In participating in these challenges, students were encouraged to work together and to overcome their differences.
And, no surprise, Ms. Gardea Butler highlights the importance of good relationships and a foundation of trust by school administrators, teachers, and principals in UR SON’s success. The UR SON SBHC team planned to utilize teachers in non-core classes such as study hall or health where the instructor could provide social support for students but, due to systems issues, they were not able to implement this.
The app developer was also supportive, providing a QR code which the SBHC distributed on posters and fliers throughout the schools to encourage students to log in. The app first rolled out in Fall 2021, distributing some 100 licenses to the students. Ms. Gardea Butler expects to increase student enrollment but, in a creative move, UR SON plans to offer subscriptions to teachers as well, who themselves have suffered high levels of stress and burnout as a result of the pandemic.
Resulting from the efforts of the UR SON SBHC team, use of the Fabulous app reached over 100 students and staff a few months into the project and continues to build.
The Challenges: Of course, the initiative faced challenges. The school requirement that students hand in their phones at the beginning of the day limited students’ ability to utilize the app during the day to problem solve and seek support with downloading if needed. Ms. Gardea Butler advises that a wellness resource with web-based options may be better suited for student use in a school setting, allowing use in classrooms and the SBHC.
The Fabulous app offered its own challenges. For example:
The goal options available within the app overwhelmed some users with the amount of narrative in coaching letters and goals. The app generates coaching depending on the user’s selected goals, which help to provide motivation and information on the goal and behaviors.
The app’s graphics are appealing to students, but the App content was not specifically designed for students. This may have an impact on the SBHC’s ability to increase adoption over the next year.
Inability to turn off “live” challenges. The app allows users to connect with other fabulous app users around the world to engage in live challenges: healthy eating, walking, focus etc.
The Future: While the original grant that funded this project ended in December, 2021, the UR SON team continues its work to increase the app’s adoption rate.
App subscriptions remain available to students and teachers and UR SON hopes to engage in a healthy school community challenge chosen by students before the end of the 2022 school year. Under consideration is a challenge where teams are composed of entire grades (e.g. 10th grade vs. 11th grade) and the winner (the team enrolling the most students) gets a healthy outing. The Fabulous app development team continues to provide support and generously extended the app subscriptions through April 2023, 6 months beyond the original expiration date.
In learning from the UR SON team’s experience, an app that offers a more specific focus on adolescent issues and concerns–ideally, one developed specifically for use by SBHCs, with components designed for students, teachers, school administrators and SBHC staff -- would be most helpful. Such an option would allow teachers, school administrators, and students to benefit while effectively increasing the SBHC’s ability to provide behavioral health support to their school communities.
Ms. Gardea Butler expressed gratitude for the resources and stipend provided by the NY School-Based Foundation’s telehealth program to explore use of a wellness app. “I definitely would recommend [the program] – it allows for creativity and opens up ways to connect with students and the school.”
Congrats to the UR SON team for their creativity and their strong and trusting relationships not only with their students, but with their teaching staff, administrators, principals and community-based planning coordinators!