School-based health centers fill rural provider vacuum - North Carolina Health News
By Melba Newsome
Growing up in a small town in central Wisconsin, many of Steve North’s relatives and friends assumed he would follow his father into medicine but North had other ideas. He earned a liberal arts degree at the University of Wisconsin-Madison in 1993 but, instead of applying for medical school, he applied for Teach for America.
For the next two years, North taught 5th- through 8th-grade exceptional education in Edgecombe County where he saw how unaddressed medical problems kept his students from reaching their academic potential.
“The kids were frequently coming to school sick or missing lots of school,” recalls North. “I started doing some reading and got turned on to the idea of school-based health centers (SBHC), which were relatively new on the national scene at the time.”
What he learned persuaded North to finally follow in his father’s footsteps and he was accepted to medical school at UNC Chapel Hill.
While practicing family and adolescent care medicine in Bakersville, a remote mountain town with fewer than 500 residents, North continued to look for ways to provide better care to the children he served. A Jim Bernstein Community Health Leadership Fellowship gave him the support and resources to start the Center for Rural Health Innovation, a non-profit dedicated to improving rural access to health care. That led to the formation of Health-e-Schools, remote clinics that provide primary care and behavioral health services for school kids.
A doctor’s office on campus
North Carolina has been trying to solve the state’s provider scarcity problem for decades with varying degrees of success. In the western part of the state, the doctor-to-patient ratio can be as high as one to 2,000 in some of the most remote areas. School-based health clinics (SBHCs) bring together educators and health practitioners to bridge the health care and education gap and help reduce the disparities that impact school children in rural burgs.
SBHCs are essentially doctors’ offices conveniently located on campus to provide a range of health care services for students, as well as for teachers and staff. For many rural, low-income residents in health care deserts, these clinics are their only access to care.
With permission from a parent or guardian, students are enrolled at the beginning of the school year and can take advantage of available resources. In addition to seeking medical attention for acute issues such as ear and stomach aches, enrollees can also receive chronic disease management, immunizations, well-child checkups, sports physicals, adolescent medicine consultants, and hearing and vision screenings.
North Carolina law also allows minors to seek medical health services for the prevention, diagnosis and treatment of sexually transmitted diseases, pregnancy, substance misuse or emotional disturbances without parental consent.
Additionally, these clinics also help reduce the number of days of classes missed by students.
“This is a good thing because when they come back after being out for a couple of days, they’re behind and it takes a while for them to get back up to speed,” said North. “If that happens more frequently with chronic absenteeism, it can be really tough to bring students back on track.”
SBHCs continue to expand
SBHCs continue to grow across the country and the state, particularly in areas with a shortage of health care providers. Some are funded through private grants but many others are supported by state and federal appropriations. Most partner with the local school district and a community health organization, such as a community health center, hospital or local health department. All are committed to serving every student, regardless of insurance or ability to pay.
When North and the Center for Rural Health Innovation launched Health-e Schools in 2011, the program served just three schools. Now, it reaches more than 25,000 students in 80 schools across three western counties, McDowell, Mitchell and Yancey.
“Parents might work 30 miles in one direction and children go to school 20 miles in the other,” said North. “Before this, when that inevitable call comes in that said ‘Johnny is sick,’ parents had to drive to school, pick up the child and go to the doctor’s office. A lot of those people would end up in the ER who probably didn’t need to be there.”
Similar alliances operate all across the state. Blue Ridge Health operates 13 SBHCs in Henderson, Buncombe, Swaine, Jackson, Rutherford and Polk counties. Many of their students have an hour-long bus ride to and from school so the convenience of on-site clinics means a child doesn’t have to miss a day of school just to see a doctor.
On the other end of the state, the Pender Alliance for Teen Health (PATH) operates three SBHCs in southeastern Pender County, filling a big gap in a place where families routinely drive 50 miles one-way to see a health care provider.
“We have certainly improved their access,” said Kimberly Collins, lead nurse for Pender County Schools. “More kids are getting their annual physicals and getting vaccinated on time. Our staff is able to see them for whatever needs they might have without having to leave work or take a whole day off, or even a half a day off.”
Using high-definition video conferencing with specially equipped stethoscopes and cameras, a centrally located health care provider can examine students at multiple schools without traveling.
As these programs continue to grow, equipping them with these tools becomes more economical, said North.
“It used to cost $30,000 to put telemedicine technology in a school,” he said. “We can now equip a school nurse for about $2,000, with a better piece of equipment that they can take from school to school.”
Behavioral care a gaping need
A study in JAMA Pediatrics found that 72 percent of North Carolina children diagnosed with a behavioral health condition waited more than a year to meet with a licensed mental health provider. According to a brief from the North Carolina Institute of Medicine, this is due in large part to the shortage of specialized instructional support personnel such as nurses, counselors, psychologists and social workers. For example, the recommended ratio is one social worker for every 250 students. North Carolina has one for every 1,427 students, according to the NC IOM report.
Lack of high-speed internet can complicate telehealth delivery in rural communities but SBHCs have made great strides in using technology to connect students to counselors, psychologists and social workers.
In September 2018, Hurricane Florence dropped more than 40 inches of rain in one day on Pender County. Up to 70 percent of the county was under water, 3,000 homes were damaged, and tens of thousands of residents were displaced. Schools remained closed for 29 days while families tried to rebuild or relocate.
By the time the coronavirus pandemic hit 18 months later, hundreds of families still lacked permanent housing.
“The pandemic is like a second wave gut punch for Pender County,” said Sandy Rowe, PATH executive director. “We were still reeling from Florence. With the poverty, remote areas and the domestic violence against our kids, they are feeling like they can’t count on anything.
“We’ve focused on doing what we can to reach them and offer services early enough in the process so that we don’t have a bigger problem later on.”
When a post-Hurricane Florence mental health risk assessment found that 30 percent of the children were at risk for depression, PATH stepped in to add two full-time teletherapy counselors and a health coach to its team of providers. It also boosted preventive measures by developing a mindfulness curriculum for teachers.
Blue Ridge has on-staff counselors for district students and Health-e-Schools partners with Mission Health to address the needs of students with complex mental health issues. Instead of missing school and possibly driving an hour to see a therapist, they can see a mental health provider and still get back to class before the school day ends.
There is a growing recognition of the value SBHCs have to their communities. In 2016, the Federal Office of Rural Health Policy and the Health Resources and Services Administration encouraged expanding access to SBHCs and provided more than $6 million in grants for rural telehealth programs. Last year, HRSA awarded $11 million to SBHCs for technological upgrades.
This is a win-win that bodes well for the growth of SBHCs, particularly in rural areas.
Melba Newsome is a 2020 EWA Reporting Fellow. This story is produced as part of EWA’s drive to support enterprising journalism that informs the public about consequential issues in education.