The School-Based Health Center Model in the Face of COVID-19
School-based health centers provide primary care, dental and behavioral health care to students nationwide. The COVID-19 pandemic is changing the way school-based health services will be provided to students for the upcoming school year. A partnership between the Weitzman Institute and the School-Based Health Alliance has brought together panelists and perspectives from across the country to provide guidance, best practices and examples as well as answer questions through a dynamic webinar series.
- April 16, 2020 – School-Based Health Centers in the Age of COVID-19 Slides | Video
- April 23, 2020 – School-Based Center Innovations: The Primary Care and Operational Perspective in the age of COVID-19 Slides | Video
- April 30, 2020 – Behavioral Health for Elementary School-Aged Patients Slides | Video
- May 7, 2020 – Supporting School Based-Health Centers; Behavioral Health for High School-Aged patients Slides | Video
- May 14, 2020 – Exploring TeleDentistry within a School-Based Health Center Model Resources| Slides | Video
- May 21, 2020 – Looking Ahead to the Future of School-Based Health Resources | Slides | Video
- May 28, 2020 – Weitzman Institute COVID-19’s Lasting Impact on Pediatric Behavioral Health Video
- June 4, 2020 – A Conversation on the Impact of Racial Injustices, Health Inequities, and Paths for Moving Forward Resources Ι Video
- June 11, 2020 – A Conversation on Racial Inequalities and the Youth Perspective Video
- July 30, 2020 – The Intersection of Public Health & Education – Sharing strategies and plans for the new year of school-based health Slides | Video
- August 6, 2020 – The Intersection of Public Health & Education – The positive impact School-Based Health Centers can make on students and parents Slides | Video
Answers to questions asked to our panelists during our sessions.
Q: What is the majority of SBHC patients have a PCP other than with the sponsoring organization in regards to reimbursement/funding?
A: CHC School-Based Clinicians are not the designated PCP for SBHC patients. Some patients have a CHC PCP and others choose community based PCPs. We are still able to bill for visits made by the school based provider.
Q: Are all of your students registered for school based health services? A large portion of our students are just traditional students. We are currently brainstorming ways to engage those who were not registered with SBH as well.
A: Yes – we initially reached out to students who are already enrolled with school based services but are now receiving new students seeking services.
Q: Is your CHC organization accepting volunteers, remote (out of CT) FNPs and PNPs to help in telehealth with the school based health centers?
A: Not currently
Q: What sorts of issues are patient visits consisting of?
A: The types of visits we have been seeing are:
- Birth control visits/reproductive care
- Screening for depression (school being closed has been a huge stressor for some of our kids in at-risk homes)
- Nutritional counseling
- Asthma follow up/allergy assessments
- ACT completion
- Safety check-ins (some DCF cases were on our list of kids we had reported to DCF but investigation still current, check ins)
- Follow-up sports injuries (with orthopedics offices closed, helping students maintain their injury or progress in healing has been helpful)
We have recognized that if we had not reached out to these families or students, the visits would not have happened.
Q: How do you begin some of these patient visits?
A: I have developed good relationships with these kids so when I call, it is also a nice catch up on things like hair color, personal life (briefly but still nice to do). If I needed or wanted, I could have a medical assistant call to make these appointments, but I find that adding one more person in the loop, it loses its value a little bit. If I get the chance to talk with a parent, I let them know we care, regardless if an appointment happens or not. We typically generate telephone encounters to show the work trail, which helps to stay organized on each student we reached out to and the outcome, but also allows for the documentation of the effort.
Q: What kind of appointments are being done through telecare? Can well visits be completed through telecare? What are some examples of some visits that can be performed through telecare by SBHCs?
A: We are currently conducting telephone appointments for asthma, allergies, hypertension, diabetes, at risk BMI, and confidential visits regarding reproductive care. Main site patients are receiving Well Child Checks and all assessments that can be conducted telephonically are being completed. The child will then come in for the more “touch” aspects of a full well child visit when we reopen for in person visits.
Q: What is your actual volume/number of primary care visits now via telecare? In other words, what is a reasonable expectations for daily visits? About what % of kids do you think you are reaching compared to when nurse was in the school?
A: Our providers see anywhere from 4-10 students a day, averaging closer to 5 daily. In our experience, the volume of patients scheduled each day is largely dependent on the number of support staff who are able to help schedule visits. We find that our support staff, when calling to schedule an appointment, are able to reach about 15-20% of the students called each day.
Q: My struggle has been that parents and students have been expressing that everything has been “fine” since being at home. They have cited that now the student is not being bullied or now the student is happy with being able to spend more time with their parents. What strategies are suggested to encourage parents/students to utilize?
A: It is great that some kids have been so resilient! Unfortunately, for some clients, that was more of a honeymoon period. This was great for a while but over time new issues are coming up or their symptoms are presenting in different ways in the home environment. While things were going well, our goal had to be shifted in a way from perfectly following the care plan at the same pace and focused on finding ways to keep the door open to care. That could mean less frequent sessions, shorter sessions as appropriate, or alternating between individual child sessions and family sessions. We tried to keep these sessions upbeat and help the client identify the skills they were using that made them so successful at home. While celebrating their success many kids are able to find room for continued growth.
Q: What are some interventions providers have done over phone sessions specifically that have been successful?
A. Phone sessions allow for some of our most vulnerable kids to stay connected and we are very grateful for that. Finding activities that still engage all of the senses have kept clients more engaged and have made the sessions more productive. We found that mindfulness techniques have translated well to phone session. We can still do guided imagery, deep breathing, and other meditative practice on the phone. Even if we can’t see each other, we can still enjoy movement so encouraging them to dance or ‘get the wiggles out’ has been helpful. Adapted narrative exercises have also been great. The kids love using their imaginations and can build stories that highlight a particular skill or overcoming an obstacle that relates to their own goals. Maybe begin with a prompt like, “let’s tell a story about a robot” or “let’s imagine a new superhero” and we talk about their special powers, their supervillain, and how they save the day. These kinds of activities can be modified to meet the age and maturity level of the client. Older kids might prefer talking about their own lived experience, imagine their older self, or use tv and video game characters instead of relying on their imaginations. Overall, try to have a few structured ideas in mind and adapt them to the individual.
Q: Are there plans to use telehealth for the dental portion of the CHC to diagnose whether a person needs emergency treatment?
A: Not currently. However, CHC, Inc. is currently looking at options for moving forward.
Q: Are you able to provide even emergency dental services? How do you handle those?
A: Our team of dentists are receiving patients for emergency dental care only.
Q: How would this benefit as a Dental Hygienist in the dental sealant and fluoride school base program?
A: Not something CHC is currently conducting but will be planning how to expand dental services with telehealth.
Q: What is being done to assist kids who normally utilize SBHCs with dental?
A: CHC is seeing patients with dental emergencies and are talking about how to bring more dental care into the tele-health arena.
Q: What type of approval did you need to start telephone/telehealth?
A: The CT Department of Social Services (DSS) provided the approval quickly as the pandemic hit CT. This allowed billing for Telehealth and Medicaid patients. Commercial billing was already in place.
Q: Do you have to be approved to do telehealth?
A: We needed to be able to bill for the services via Telehealth and CT Department of Social Services provided the approval to bill Medicaid for Telehealth. Commercial insurances were already approving.
Q: Was it difficult to get Medicaid permission to have your medical and behavioral health providers to work remotely from home?
A: There were many healthcare leaders working with CT Department of Social Services (DSS) to gain approval to bill for Telehealth via Medicaid and DSS recognized the need as the pandemic hit CT.
Q: How did you obtain consents for Telehealth? Does FERPA or any of education laws support Telehealth services?
A: CHC was able to retrieve verbal consents for telehealth according to our State’s decision during Covid19.
Q: Has CHC continued to accept new patients? What system do you use for electronic signatures for consents/HIPAA policies, etc.?
A: Yes, CHC is currently accepting new patients. At this time, we are able to obtain verbal consent for behavioral health and medical visits, and are able to complete intakes by phone. We retrieve written or electronic consent which is embedded in our electronic and/or hard copy enrollment.
Q: Are you obtaining verbal consent from parent/guardian for each telehealth visit?
A: Verbal consent is obtained for the initial telehealth visit. It is obtained by the support staff that calls to make an appointment, as well as the provider prior to starting the appointment.
Q: Does CHC’s consent form have telehealth listed as a service?
A: Our current consent form does not have telehealth listed as a service; however, we are working to add that in for future use.
Q: Is the consent obtained verbally only? or if not, how do you get the written consent signed?
A: In the current environment for existing patients, verbal consent is given to begin telehealth services. New patients complete our electronic enrollment form through Docusign, and then provide verbal consent for the telehealth visit.
Q: How do you handle getting a new student registered remotely and filling out paperwork/ consents if they don’t have computer?
A: At this time, we are able to obtain verbal consent for visits. Obtaining consent has been built into templates to ensure that it is documented in our EHR. The electronic enrollment form can be completed on a phone, though it can be more cumbersome using a mobile device than on a computer.
Q: Has CHC, Inc. created a form for parents to give consent to a caregiver or relative to sit in on a session?
A: We do not at this time. The parent/guardian gives verbal consent for another caregiver or relative to sit in on the session.
Q: For SBHCs continuing with telemedicine, how are you approaching new patient registration for EHR and consent? Are registration questions and signatures required for HIPPA and consent being collected over the phone?
A: At this time, we have not had new medical SBHC patients. If a new patient is seeking telemedicine with our SBHC providers, we are able to obtain consent for visits over the phone. Consent questions are built into our telemedicine templates in our EHR. In the current situation, CT Department of Social Services has lifted the requirement for written consent for care.
Q: Can you speak more to consents? We just responded to the COVID crisis and immediately transitioned our services to telehealth (medical and mental health). Even though all of our students are consented, should we be exploring the need to obtain a new consent?
A: This varies by state. In CT, we do need additional consent for telemedicine, even though we have consent for SBHC services. Consent is obtained verbally over the phone at the time of the visit.
Q: Can you address billing for the telehealth visits?
A: We are able to bill Medicaid and Commercial insurance for telehealth visits in CT currently.
Q: For the students that are not insured and are using Telemedicine how are you structuring the billing?
A: Fees for school based visits are waived for uninsured. We also work with the family and help them navigate the insurance system to see if, in fact, they are eligible
Q: Are there guidelines/restrictions regarding provision of telehealth by SBHC counselor and counseling support by school support staff within the same day? Parents have expressed concerns about their child being seen by a SBHC clinician and school staff because of billing. Could you clarify if there are restrictions?
A: We want to avoid duplicating services, however a school counselor (generally focused on academic outcome) and a school based health clinician (generally on issues outside of academics – although may impact academics) are working on different goals with completely different treatment plans – so generally not a duplication.
Q: Does insurance in your state cover this the same way they covered telehealth- BH Clinician in a RI SBHC.
A: Video is typically covered at the rate of an in person visit rather than of a pure phone visit. Texting is not used for any Clinical communication, only for reminders and follow-up appointment.
Q: How are the salaries paid for your staff? Do the schools reimburse the organization or where do the finances come from?
A: Our SBHC program is largely sustained by insurance reimbursement. A few have funding from the CT Department of Public Health, but the funding is minimal.
Q: How is CHC Inc. communicating with students/families about services being offered via telehealth? What have you found to be the most successful methods of communication when school is closed? Telephone? Text?
A: Initially, we wrote an email directly to the Principal and Assistants, as well as the school nurse. Then sent out a blast email to the students giving them a direct office # and email address. In addition, shortly after that, we contacted guidance counselors and Special Ed teachers. A week into telehealth, we began calling students and parents directly. We did not use an assistant to call and have used email and telephone as means of contact.
Q: Do you have recommendations for eliciting information from students/parents/schools on how best to support them during this time (their needs, best mode of outreach, etc.)? We are doing some strategic planning for our outreach and want to make sure we are developing programs or modifying existing programs in a meaningful way.
A: Students prefer texting, but if using a blocked number it may not work. We have Zoom phone #’s as well. Our experience demonstrates that the best success has been student’s personal cell #s . Parents have had specific questions about COVID, about where in the community to go for testing, and how to address the need to be with friends and connecting with others, while keeping their kids safe at home. (a balance many parents struggled with before the Stay Home orders and this just magnified the issues); Many parents needed and need emotional support and outlets for their struggles, which is important. So having community resources available during your calls to students is very necessary and appreciated. Things such as meals, counseling, financial services, etc…)
Q: Do you have community/parent advisory councils associated with your school based health centers? If so, are you staying in contact with the council or are you holding virtual meetings?
A: We have PTA’s, but they are not directly associated with our SBHC’s.
Q: Does CHC, Inc. have any restrictions to reach out to all student and families in the school? Or are you only reaching to your patients?
A: The entire student and parent body received an email with our contact information but the only students we are calling on are our current SBHC students. However, if any new students or newly identified needs arise, school staff have and will continue to reach out to our SBHC as they always have, in order to connect for services.
Q: How are services supporting students/families who don’t have or difficulty with WIFI?
A: Medical visits are conducted by phone, so no Wi-Fi is needed, only telephone service. Many of the internet vendors were offering great discounts on service during this time and we shared that information as far and wide as we could.
Q: Is CHC, Inc. calling all patients or just patients that have chronic health issues? Do you have a basic questionnaire developed to ask families about issues around food security/etc.
A: At this time, we are only calling patients that have one of the following issues associated with a previous visit: at risk BMI, diabetes, hypertension, asthma, allergies, or confidential reproductive healthcare needs. We are focusing only on these conditions as we are not the PCP, and are only scheduling visits for those that would have received follow up in the SBHC if schools were open. If a family would like to schedule their student with us for another reason, they are able to do so; however, we encourage people to seek care from their PCP when possible.
Q: How do FERPA/HIPAA rules work with access to the Powerschool tool?
A: We have access to PowerSchool in our MOU with the districts we serve. The district can limit access to only the info we need such as a student schedule and perhaps attendance. Parents provide consent for “HIPPA and FERPA” to have limited exchange of information that will assist with a student’s academic outcome
Q: How can the school nurse share information for the health centers without breaking FERPA/ HIPPA?
A: On our enrollment, there is a consent provided by parent/guardian for a child’s academic success and allows “HIPPA and FERPA” to have some ability for two way communication – but still protecting a student’s right to privacy.
Q: In regards to HIPPA and STD screening/testing, how is this done and not have parents awareness?
A: In the State of CT, confidential care rights begin at age 13. Contacting the students directly, and asking about their privacy before the call topics begin, is essential. Typically, the student will contact me with the best time and # to reach them and then when we connect, I ask them some very direct questions about where they are, confirm patient identifiers, and talk about some mental health and health topics first, and then discuss reproductive care. If it is private insurance, we use an unbillable code for the visit. HUSKY does not send EOB’s to home so that helps with privacy concerns. Most pharmacies allow for the pick-up of contraception and our students know their reproductive rights, which helps with care.
Q: What platform did you use to send documents?
A: CHC uses Docusign for any documents that the patient needs to sign. We send the links to Docusign via Zoom Chat with the patient.
Q: Do you have any advice or models you are using for texting with patients?
A: We are using a mass texting service called SolutionReach to send out day before reminders with hyperlinks to video guides on how to join. We then also send additional reminders with the hyperlink to join the provider day of appointment. Each provider also has a softphone via Zoom Phone that they can use for individual appointment reminders or reschedule, but that we do not use for Clinical communication.
Q: Our LPHA is banning Zoom due to security risks. Is Zoom safe for HIPAA and virus protection?
A: Zoom has the same encryption configuration as other mass video products. 132 bit AES still has not been broken, and with a paid telehealth account it meets all the requirements of HIPPA when appropriately used.
Q: How much does zoom cost per provider?
A: This depends on how you want to pay, either $15 per provider per month or if you use a longer contract you can get a discount. We pay $100 per provider per year.
Q: Do you have any concerns with the recent Zoom privacy and security problems reported, especially with the end-to-end encryption issue?
A: End to End encryption is not the default for most video systems, especially those that we could use for groups. Microsoft Teams, or Discord, or Google Hangouts are all not End to End encrypted. Zoom is encrypted, both in transit and at rest, which is still better encryption than most any other PHI would go with. The great majority of Zoom security issues are from unsecured public meetings, no telehealth meeting should be unsecured.
Q: Can you explain more about Zoom Phone?
A: Zoom Phone is an additional license you can buy from Zoom. It takes the Zoom app that you would use for a video call and lets it also make regular phone calls and texts. It let us quickly get work phones into the hands of all our providers and MA’s and dental staff that just got sent home.
Q: How can we use the Zoom platform to reach students?
A: You are able to share your screen and annotate on a whiteboard, or a shared picture to give another method of communication or even art therapy. Here is a video we found that might help. https://www.youtube.com/watch?v=QGQkAsKtriU
Q: Are there security issues using Zoom if you are using the free version?
A: The Free Version of Zoom does not meet all the tenants of a HIPPA secured form of telehealth communication. I would advise against any PHI on a free Zoom account.
Q: What about utilizing Doxy.me to simplify connecting with your less tech-savvy patients?
A: Doxy.me fits a very similar role as we are using Zoom Phone with in our agency. Both are software phones that can be used to call without exposing the provider’s personal phone number. For CHC, Doxy.me did not provide enough enterprise level oversite or control for us to be comfortable with using it for our agency.
Q: Do you have a comprehensive platform to consolidate texts, phone/voicemail messages to organize messages for staff and patients?
A: Yes, we are using SolutionReach as a texting service, this provides a backend to track mass texts sent. We mass text appointment reminders and a guide to connecting to zoom with video hyperlinks. Then for the one on one calls and texts as follow-ups we tend to use Zoom Phone which gives us a dashboard were we can monitor calls and messages sent.