The Future of Virtual Speciality Care for Rural SBHCs: Bassett's Pediatric Pulmonology Services
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. The NY School-Based Health Foundation (the Foundation), with the support of the Mother Cabrini Health Foundation, developed a telehealth technical assistance program to support SBHCs in making the transition.
Emerging from the program were many creative uses of telehealth to meet children’s health care needs. Our first ever Telehealth Story Contest identifies some of the most innovative which we want to share in the hope of inspiring others. This is the story of how Bassett Healthcare Network was able to assist their SBHCs in offering virtual pediatric pulmonology care to their students with asthma. Special thank you to Nurse Katelyn Stewart (RN III) for her story submission.
*To protect patient confidentiality, the students’ identifying information has been changed.
Anxiety Around Asthma in the Early Pandemic Days:
Controlling asthma in children and youth has been an ongoing battle for providers everywhere, especially in the wake of a deadly virus whose main symptoms include coughing, shortness of breath and difficulty breathing. For the SBHC team at Bassett Healthcare Network, improving outcomes for children with asthma has meant expanding their virtual care options, even before the COVID-19 pandemic began.
One elementary school student in particular, Alex*, exemplifies the need for access to quality pediatric pulmonology care. Alex struggles with severe asthma and during the first few months of 2020, their asthma had not been well controlled. Knowing this, Alex’s primary care provider attempted to switch their medication but it resulted in minimal relief.
Then, at the beginning of the COVID-19 pandemic, Alex was hospitalized for an extreme asthma exacerbation. Alex’s mother was traumatized, understandably so at the beginning of a deadly pandemic with new strict hospital visiting guidelines.
After Alex was discharged, their primary care provider referred them to a pulmonologist, a physician who specializes in the respiratory system. Due to the constraints of the pandemic, Alex saw a pediatric pulmonologist, Dr. Voter, virtually through Bassett’s SBHCs who partnered with Rochester.
Nurse Katelyn Stewart assisted in this visit and recalls how relieved Alex’s mother was to finally be able to speak with a specialist and have her child properly evaluated. Dr. Voter was able to adjust Alex’s medications and follow ups showed their asthma control had improved tremendously.
Challenges of Delivering Care in Rural Communities:
Alex’s family had neither the time nor the financial resources to travel to Rochester to seek speciality care. Bassett’s 21 school-based health clinics are spread out among three different rural counties: Otsego, Chenango, and Delaware counties. From each, it is a two to four hour commute one-way to Rochester or Albany, where many specialty providers are located. For many families living in rural New York, the distance constitutes a major barrier to accessing needed health care.
To ensure access to care, Bassett’s SBHCs offer physical examinations, comprehensive health care, preventative dental services, and mental health services in the same school buildings where students attend classes. Their clinics serve children and youth from Pre-K until 12th grade, and any student who is enrolled in the school district can access Bassett’s services.
Without adequate specialty providers, however, there is only so much that Bassett can do to address their students’ more specific health issues. As of 2019, around 1 million students in over 1800 primarily rural public schools across the nation utilized telehealth to access their SBHCs. To address poorer health outcomes in rural communities, SBHCs used telehealth to tackle professional shortages, long distances to providers, and lack of transportation (1).
A 2019 study published in the Journal of Global Pediatric Health examines and compares the use of telehealth in SBHCs to traditional in-person SBHC care. Researchers found that telehealth exclusive SBHCs were far less likely to be multidisciplinary compared with traditional SBHCs (1). This study also showed that, while some rural SBHCs had prior telehealth experience, telemedicine services were underutilized, as was the case with Bassett.
Unlike many other health organizations, telemedicine was a regular part of Bassett’s services even before the COVID-19 pandemic although, like the study, it was not being used to its fullest potential. Bassett used telehealth primarily to connect SBHCs to one another, especially when a physician and the student were located in different sites. Bassett’s facility with telehealth enabled it to smoothly transition to offering telehealth visits during the pandemic. Jane Hamilton, who manages School-Based Health Care at Bassett, spent years working to expand their telehealth services and offer virtual pediatric pulmonology to their students with asthma
Lack of pulmonology care has been an issue since before the pandemic. For instance, COPD is a group of respiratory conditions, including chronic bronchitis and emphysema, which makes breathing difficult for millions of Americans. According to the CDC, COPD comprises the majority of deaths from chronic lower respiratory diseases, which was the fourth leading cause of death in the United States in 2016 (2).
Additionally, rural populations may have more COPD-related issues due to higher rates of smoking, increased exposure to secondhand smoke, and less access to smoking cessation programs compared with people living in more urban areas (2). The same CDC report indicated that rural residents are also more likely to be uninsured and have higher poverty levels, which may impede access to early diagnosis and treatment (2).
Asthma is the most common chronic illness of children and adolescents in the United States (3). While asthma is commonly understood to disproportionately impact urban dwellers, recent studies have revealed rural pediatric asthma prevalence to be very similar to urban and to be more closely correlated with socioeconomic and environmental factors than geographic location or population density (3).
Rural children and youth experience asthma-inducing factors such as housing quality, cigarette smoke exposure, and small/large-scale farming (3). Additionally, barriers to accessing asthma care are more common and challenging for those living in rural areas, including insurance status, lack of primary care providers and pulmonology specialists, knowledge deficits (both patient and provider), and a lack of culturally tailored asthma interventions (3).
As was Alex’s case, for many students using Bassett clinics, the nearest pulmonologist is in either Rochester or Albany, requiring hours’ worth of driving. Beyond the financial barriers to undertaking such a trip, many families find it disruptive for parents to lose time from work and for students to take time off from school. This is where Bassett’s understanding of the communities they serve and their commitment to expanding access to specialty care for rural communities is especially vital.
Addressing Barriers through Virtual Speciality Care:
In an effort to address the gaps in asthma care experienced by their students, Manager of School-Based Care, Jane Hamilton, piloted Bassett’s virtual pediatric pulmonology services with the help of her staff.
Access to asthma specialists for rural children and adolescents is critical to improving asthma outcomes, according to a 2017 study on rural asthma prevalence and interventions (3). In particular, management via telemedicine has shown equivalent or improved asthma outcomes for rural children and adolescents as compared to in-person specialty visits, and exhibits high patient acceptability (3).
A 2016 controlled clinical trial of children with asthma came to similar conclusions, finding that telehealth is just as effective at controlling asthma as in-person services, achieving comparable degrees of asthma control (4).
Knowing of telehealth’s successes, Ms. Hamilton partnered with the University of Rochester to expand their virtual pediatric pulmonology services. The logistics of this collaboration took many years and a lot of hard work, but once the program was up and running, its positive impact on students and their families was apparent.
According to Nurse Stewart, the program allows patients physically in their rural school clinics to meet with a specialty pulmonologist without traveling over 100 miles to get there, “This is a lifesaver for our families who do not have the means to travel to the city for care. It is truly amazing how accurately the pulmonologist can hear the child’s lung sounds and assess them from such a great distance away.”
The telemedicine process involves real-time use of a Remote Presence Solution (RPS) equipped with a digital stethoscope, otoscope, and high-resolution camera (4) which cannot be done at home because of the lack of equipment. Thus initially, telemedicine visits were conducted through MyChart as video visits and included some acute visits, but primarily ADHD management and depression screenings.
Despite school closures, Bassett’s school-based health clinics remained open for students who needed to be seen in-person by a provider. Once schools reopened, the SBHC team at Bassett was able to soft-launch their virtual pulmonology services.
Nurse Stewart and her colleagues solicited referrals for their virtual pulmonologist from their SBHCs and pediatric providers. While virtual pulmonology is also being offered at all of Bassett’s main pediatric clinics, Nurse Stewart notes that utilization is higher and the need is much greater in school-based health settings.
The SBHC pulmonology team currently offers services one day a month, which has been sufficient to date. Nurse Stewart notes that the program took off right away, and since then their schedules have been full every month. While they eventually aim to further expand the pulmonology program, the team faces certain challenges.
Proper Training to Ensure Quality of Care:
While poor Internet connection is a barrier to conducting any telehealth visit, there are multiple considerations beyond connectivity in play before telemedicine initiatives can be implemented into usual care. These include the patient’s and the health care provider’s social support and interaction, individual characteristics and resources, negative associations, and usability (5).
For Bassett’s SBHC team in particular, the use of new pulmonology technology required the proper training of providers, most of which involves how to use the new program. Nurse Stewart created a one-pager to aid staff training and traveled to all of their SBHC sites to train providers. She found that their SBHC staff largely knew how to use the equipment, but needed to learn how to set it up properly for pulmonology.
Once staff had been trained, Nurse Stewart was pleasantly surprised at the easy use of the existing telehealth equipment, and students are impressed as well, “The stethoscopes provide such high quality sound that the doctor is able to hear every little wheeze and crackle.”
The Takeaway:
Since the program’s start almost a year and a half ago, there have been over 40 visits scheduled and still counting. Nurse Stewart notes how students and families are amazed by the equipment and technology to provide such services remotely, “Our existing clinics already have a very close relationship with each school district they reside in. The addition of this program has been heartily embraced by the communities who have used it so far. Most are floored by the opportunity to have their children seen by a pediatric pulmonologist without leaving the village.”
Bassett launched their virtual pediatric pulmonology service as a start up of a wider array of virtual specialty visits. In the future, Nurse Stewart expects to expand to more specialties such as neurology and endocrinology for the organization. For now, they are overjoyed by the results of their pulmonology services and look forward to continuing to expand access to specialty care for rural communities in New York.
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