New York School-Based Health Foundation Intern, Sarah Bacio, speaks to School-Based health professionals who share their impressions on the use of telehealth for administering care to at-risk students in the midst of the COVID-19 pandemic.
In the mid-April peak of the COVID-19 pandemic, in-person health visits fell by nearly 70%, with telehealth visits offsetting as much as 20% of that decline (1). Anna Mond Johnson, CEO of the American Telemedicine Association (ATA), speaks on the importance of strengthening telehealth services during such uncertain times, “telehealth has played a vital role in responding to the pandemic, driving a rapid transformation in how care is delivered. Working together, we must ensure access to care for all who need it” (1).
The greatest increase in telehealth was recorded in the Northeast, the region hit hardest by the pandemic in March and April, with a 15,503% increase compared to 2019 (3).
Schools are an essential source of non-academic support for many students including health services, food assistance, and intervention in cases of homelessness and domestic violence. For students who rely on school-based health services to receive vital primary, dental, vision, and behavioral health services, the abrupt school closures in March and April left students and providers to immediately transition to a telehealth model. However, for many School-Based Health Centers (SBHCs) across the country, telehealth was already employed as a tool to reach students in rural areas and to perform check-ups when limited specialists were available.
As of 2019, around 1 million students in over 1800 public schools utilized telehealth to access their SBHCs, primarily in rural communities who tend to have poorer health outcomes due to health professional shortages, long distances to providers, and lack of transportation (2). Given these barriers, prior to the pandemic, telehealth was primarily seen as potential to expand the reach and scope of services of SBHCs.
In a study published in the Journal of Global Pediatric Health in 2019, the usage of telehealth in School-Based Health Centers is examined and compared to traditional in-person SBHCs. Researchers found that telehealth exclusive SBHCs were far less likely to be multidisciplinary compared with traditional SBHCs (2). While nearly three quarters of traditional SBHCs had a behavioral health provider, only one quarter of telehealth exclusive SBHCs provided access to behavioral health. Furthermore, on average, traditional SBHCs using telehealth were 10 times more likely to be open in the summer than telehealth exclusive SBHCs, which can have a major impact on continuity of care (2).
Given this data, it is clear that although SBHCs had prior experience with telehealth in rural communities, it was a service that was underutilized and lacking in many regards. With the need for expansion of telehealth due to the pandemic, it is important to examine the differences in administering telehealth between primary and behavioral health care. With this mind, I interviewed both a primary care provider and behavioral health specialists who work in school-based health care across New York to gather their experiences pre- and post-pandemic in utilizing telehealth.
Telehealth in Primary Care
When the pandemic hit, primary care providers (PCPs) and specialists began using telehealth in record numbers. The greatest increase in telehealth was recorded in the Northeast, the region hit hardest by the pandemic in March and April, with a 15,503% increase compared to 2019 (3). For primary health in particular, virtual care was a modality that was left unexplored, leaving many providers feeling unprepared as coronavirus pushed healthcare systems to find new ways to administer care. Dr, Cynthia Zelis, Chief Medical Officer at MDLIVE, views telehealth as the next frontier in medicine and an opportunity to improve patient care by enhancing the ability to be proactive and monitor patients regularly (3).
“I personally am very conscious when I prescribe antibiotics, and it is not something I would do over a telehealth visit. If I felt a child needed antibiotics, I would send them in for an in-person visit first.” -Dr. LeBLanc
Dr. Kerri LeBlanc, the Director of the School-Based Health Program at Bassett Healthcare Networks, spoke with me about how the pandemic pushed Bassett’s program to improve its virtual care practice. At Bassett Healthcare Network, Dr. LeBlanc oversees 19 SBHCs that provide services ranging from comprehensive health care to dental and mental health for thousands of students in rural areas of New York. Prior to the pandemic, Bassett’s SBHCs would utilize telehealth to treat students with concussions who needed doctors’ clearance to return to class. According to Dr. LeBlanc, they found it was useful in getting students in rural areas faster care, but it was inefficient as it required both the time of both the doctor performing the check and the nurse practitioner who ran the visit in the school health clinic.
Although Bassett’s SBHCs had experience in telehealth, the scope of its services was still greatly limited, “In a way, the pandemic really forced us to get more comfortable with our telehealth practice. I’m grateful for it in that way because I think we needed that push” says Dr. LeBlanc, adding that since Bassett SBHCs already had the training and infrastructure prior to the pandemic, the transition to telehealth was much smoother than for other practices without that experience. She also notes that having strong telehealth services is especially important as the 2020-21 school year will likely be in and out of in-person instruction, and solid training and infrastructure will allow SBHCs to easily adapt to these changes and provide much needed care.
Throughout the past few months of administering virtual care. Dr. LeBlanc’s main concern is over prescription of antibiotics. In a study conducted by the University of Pittsburgh, they found that children received antibiotic prescriptions during 52% of telemedicine visits, compared with 42% of urgent care and 31% of primary care provider visits (4). Dr. LeBlanc feels that practitioners need to be especially aware of their prescribing practices when using telehealth, “I personally am very conscious when I prescribe antibiotics, and it is not something I would do over a telehealth visit. If I felt a child needed antibiotics, I would send them in for an in-person visit first.” In order to accommodate these in-person visits, Dr. LeBlanc’s practice at the peak of the pandemic set up outdoor tents to ensure the safest conditions possible. Although she sees telehealth as a valuable tool, Dr. LeBlanc is clear that she would not want virtual care to replace her in-person practice, “I see telehealth as a valuable tool in administering care, but at the same time, I enjoy having face-to-face interaction with my patients, it’s something I value and miss.”
Telehealth in Mental & Behavioral Health
Behavioral health is an area of particular concern when it comes to treating students during coronavirus as mental health issues can be easily exacerbated by social isolation, loss of family members to the virus, and financial concerns due to rising unemployment. Previous research exhibits how quarantining and pandemics can impact young people’s mental health. In a survey of children aged 6 to 12 in Wuhan and the nearby city of Huangshi, in China, more than one in five children reported symptoms of depression and experienced ongoing anxiety after coronavirus quarantine was lifted (5). Past studies of children in parts of the U.S., Canada, and Mexico who were quarantined during outbreaks of H1N1 (2009) and SARS (2003), found that 30% met clinical criteria for PTSD—a rate similar to that of child abuse victims (6).
Behavioral health specialists warn that unless New York state makes radical changes, many young people will not be able to get the mental health care they need. New York in particular has just 20 child psychiatrists per 100,000 kids (8).
In the US, we are starting to see the number of young people coming to hospitals with dangerous psychiatric emergencies increase after plummeting in the weeks following school closures (7). Dr. Vera Feuer, Director of the pediatric emergency psychiatry at Cohen Children’s Medical Center, states that incoming cases she is starting to see are more likely to be acute as well as an increase in serious suicide attempts that require medical treatment in addition so psychiatric care. Behavioral health specialists warn that unless New York state makes radical changes, many young people will not be able to get the mental health care they need. New York in particular has just 20 child psychiatrists per 100,000 kids (8). While this ratio is better than other states, it still leaves many children without anyone to turn to in the event of a crisis. School-Based Mental Health services are able to offset much of this demand, with studies showing that the barriers experienced in traditional mental health settings– stigma, non-compliance, inadequate access – are overcome in school-based settings (9).
At New York Presbyterian (NYP), a provider that serves 7 SBHCs in New York City, behavioral health is a key component to their SBHC model and vitally important for students they reach. According to Kelly Kirby, LCSW-R, Mental Health Program Manager at NYP, prior to the pandemic, telehealth was used on a limited basis for follow-up psychiatry appointments across the various SBHC sites. In order to transition to a fully telehealth model due to the school closures, the SBHC program at NYP had to conduct a huge outreach effort to get students and families onboarded to the virtual telehealth platform and ensure that students who were in the middle of their treatment could continue to access their behavioral health provider.
When asked about how the students have been transitioning, Ms. Kirby has found that while some students have struggled, others who had previously dealt with anxiety in school have flourished with online learning, which allows them to stay home and not deal with the social anxiety triggers they face at school. Dr. Donya Rhett, a supervising psychologist and clinician for the NYP School-Based Health Program, speaks on the effectiveness of using telehealth for mental health purposes, “I’ve been providing part-time mental health services through telehealth in private practice role for about 3 years now and so I know that people embrace doing therapy virtually, and they do well with it. It eases access because people have their busy schedules but still have access to therapy.”
While many young people are embracing virtual therapy, it is not without its challenges and barriers. For New York Presbyterian Hospital's SBHCs, behavioral health providers have encountered many young people who do not have the technology and/or privacy they need to comfortably conduct therapy sessions. These challenges required their team to adapt quickly, “With the technology piece we really put on our case manager hats in a lot of instances and tried to help connect families to resources,” says Dr. Rhett, continuing, “there might be times where a young person has fewer people in their house so typically we wouldn’t be doing a session at 6 o’clock in the evening, but because of the pandemic, we had to accommodate so patients could get the care that they needed.”
We have such clear racial inequities in how our healthcare system operates now, we need to make sure the digital divide doesn’t widen them.” -Alice Bufkin
Dr. Rhett points out that NYP oversees SBHCs in the Bronx, Washington Heights, Inwood, and Harlem, and their student population tends to consist of Black and brown low-income families, “The young people that we serve in our schools, many of them come from families where they qualify for free lunch, some of them are homeless, a disproportionate number of the students on our campuses are in shelters or temporary housing or cohabitant (living with other families) so they didn't have the ideal access.” The pandemic has already highlighted disparities among low‐income Americans and some racial and ethnic minority groups, including Blacks, Hispanics, and Native Americans (10). A recently published study on COVID-19 infections among children are showing similar trends, with 30% of Black children and more than 45% of Latinx children testing positive compared to 7% of white children (11). Looking at the social determinants in Black and brown low-income students, some of these children were already struggling prior to the pandemic. For them, COVID-19 compounded the existing stressors in their lives, “So while this was a big trauma for most of America, for many of the families we serve, the pandemic has just been another layer added to the history of complex trauma” continues Dr. Rhett.
Therefore, the access piece is especially important when looking towards the future of telehealth. “We have such clear racial inequities in how our healthcare system operates now," Alice Bufkin, the director of policy for child and adolescent health at the Citizens’ Committee for Children of New York, says. "We need to make sure the digital divide doesn’t widen them.” Ms. Kirby and Dr. Rhett echo this sentiment, stating that their biggest hope for the upcoming year is that all students receive the technology and wifi they need to access care.
“I am sensitive to this idea that we don't want to throw out in person support. There's so much of the whole person and nonverbal and I am looking forward to when we can do those in person sessions again.” -Ms. Kirby
Ms. Kirby also points out the challenge and unique opportunity with telehealth to have more of a connection with families and parents to coach them through skills to help their students, “you have the opportunity to be more empathic, because you can see things as they’re happening and intervene more effectively. Much of the work is about helping the parent have a different lens and maybe different approach to interacting with their child.” While Ms. Kirby sees the usefulness of telehealth, she is of the same mindset as Dr. LeBlanc from Bassett Healthcare, stating, “I am sensitive to this idea that we don't want to throw out in person support. There's so much of the whole person and nonverbal and I am looking forward to when we can do those in person sessions again.”
For administration of both primary care and behavioral health services, telehealth can be a useful tool in engaging students who do not have access to healthcare. However, in both cases, specialists point that should be seen as a tool as opposed to a replacement to the in-person model. For SBHCs, telehealth can be utilized as a way to improve education and familial outreach, as well as to treat students who do not feel comfortable seeking in-person care. Through this new modality, SBHCs have the opportunity to reach a wider range of students, an especially important task during the current pandemic. However, it is important that through their efforts to promote new modalities, SBHCs keep in mind the differential barriers present across each modality, and do their best to ensure equal access to primary care and behavioral health services.