Implementation
A successful school-based health telehealth (SBTH) program requires collaboration between key health and education stakeholders to develop an effective program and lay the groundwork for growth and sustainability. Remember to work closely with school health staff, such as school nurses, counselors, and social workers, and school district leadership during the implementation process.
Key Considerations
Workflow & Pilot
Create and document a workflow that describes each person’s role in a successful SBTH visit including the program manager, coordinator, school nurse, telepresenter (if someone other than the school nurse serves in this role), and provider(s). Note, a program may develop more than one workflow to describe the telehealth services offered. For example, an on-demand workflow for acute visits and a scheduled visit workflow for chronic care visits. It is important to optimize the efficiency of the school nurses’ role within the SBTH program, especially if they serve as the telepresenter. Best practices for increased telepresenter efficiency include the following:
- Ensure ease of technology use
- Consider an electronic scheduling and request system, especially if there are multiple provider groups available to deliver care to the same location
- Ensure the workflow at the health center site promotes a rapid response and connection
Piloting the program before start-up or expansion refines the workflow. Selecting a pilot location with a highly engaged, school nurse and/or a principal that is enthusiastic about the program is beneficial and ideal. Review the Program Evaluation section for suggested process metrics to collect at this phase of your SBTH program implementation.
A successful school-based health telehealth (SBTH) program requires collaboration between key health and education stakeholders to develop an effective program and lay the groundwork for growth and sustainability. Remember to work closely with school health staff, such as school nurses, counselors, and social workers, and school district leadership during the implementation process.
Setting up the Space
SBTH staff should set up the telehealth equipment in the office of whoever will serve as telepresenter to maximize space and efficiency. This may be a designated space in your school-based health center (SBHC)—for existing school-based health programs—or in or near the school nurse’s office. For programs where the telepresenter rotates, portable telehealth equipment moves from school to school. Below, are areas of consideration when selecting a location for the telehealth equipment:
- Select a private area
- Use a dedicated data port for the telehealth equipment to access the internet
- Set up the equipment away from a window (unless there are blinds to support privacy and block the light from interfering with the camera)
- Ensure the camera points away from windows or bright lights
Policies and Procedures
Just as with an SBHC program, it is important to develop policies and procedures. Below are the topics and items to include in a SBTH Policy and Procedures resource. An example of a SBTH Policies and Procedures document is included in the Resources Spotlight below.
Topic | Items for Consideration |
Caregiver Rights and Responsibilities | Overview of the consent process |
Clinical Services | Outline description of the services offered in program |
Collaboration with Primary Care Providers (PCPs) | Record sharing with a student’s PCP according to confidentiality laws |
Confidentiality | Compliance of each employee and partner of the SBTH program with relevant general statues and other rules that affect the confidentiality of students and personnel for accessing, maintaining, and documenting in the medical record |
Consent for Care | Note that consent forms must be signed prior to a visit; decide whether program will accept verbal consent |
Eligibility | Identify who is eligible to receive services in program (i.e. students enrolled in program) |
Fee Plan/Billing | Establish how providers will bill for services and school nurse facility fee billing practices |
Financial Policy | Will the program bill for services and will insurance cover the telehealth visits |
Hours of Operation | Establish when services are offered and where students should seek care when the SBTH program is not available |
Laboratory – Clinical Laboratory Improvement Amendments (CLIA) Compliance | Share a copy of the CLIA Waiver Certificate and quality control process |
Laboratory Tests | Review the types of tests that are offered |
Medical Records | Identify where the medical records will be maintained and develop a records release process |
Operations Manual
In addition to developing policies and procedures, your SBTH planning group needs to document the information below for both the SBTH program staff and school health staff (e.g., school nurse, school counselor, school social worker, etc.).
- Workflow, including when and how to request a visit
- Equipment overview
- Troubleshooting tips
- Technical support contact information
- Steps to take before, during, and following the encounter
- School nurse billing processes and required documentation
- Program resources; including a school excuse form, provider letter to parents, and fax cover sheet
Memorandum of Understanding (MOU)
A services agreement, or an MOU, outlines the responsibilities of both the health center and the school district. Below are items to consider including in your SBTH MOU (see the Resources section for an example school-based services agreement and telehealth addendum). If you have an existing SBHC MOU and you are expanding the program to include telehealth, you may be able to execute an addendum for the telehealth component of the program.
MOU/Services Agreement Topics | Areas to Include |
Responsibilities of health center
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Responsibilities of district/school
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Joint responsibilities |
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Other items to consider |
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Consent Forms
Establishing a successful consent process is a vital part of an SBTH program. Focusing on efforts to generate enrollment into the program can support increased utilization. Steps to creating a consent process include developing, distributing, processing, and sharing the completed forms securely across school partners and the SBTH team. Offering electronic consent forms can reduce printing costs, increase form security, and streamline same-day enrollment.
Development of Consent Forms
First, consult with your health center’s legal counsel and compliance team to create a form that includes the following components: demographic information, consent to treat, HIPAA Authorization, and FERPA. Be sure to use the demographics to determine the needed consent form translations.
Consent Form Distribution
Collaborate with your school district partner early to define an effective consent form distribution plan. Explore opportunities to mimic the school district’s registration process (electronic vs. paper) for enrollment in the SBTH program. For example, if the school distributes an annual registration packet, include the SBTH consent forms in the packet. If a school district registers students electronically, collaborate with the district to include the consent link or integrate the electronic consent forms into the registration software. Caregivers already in the process of completing paperwork for their students and may be more likely to complete the consent forms.
Consent Form Processing
Make a plan for collecting and receiving completed consent forms. Develop a process for storing the forms and ensure everyone on the SBTH team has the necessary access before a student sees a provider. For example, the program coordinator will likely need access to the forms to register and schedule the student in the health center’s electronic health record (EHR). If using paper consents, fax the consent form prior to the student’s visit. If using electronic consents, determine where the completed consent forms are stored. Are the forms in the school district’s software or the health center’s software system? If the consent forms are stored in a school district’s software, collaborate with the district to develop a plan for how the health system will retrieve the forms. Consider proactively creating patient charts and uploading the consent forms into the record as soon as a student enrolls in the program.
Consent Form Sharing
After identifying a system for securely sharing and processing the consents, develop a system to provide an updated list of enrolled students to relevant school health staff (school nurse, school counselor, school social worker, etc.). Consider collaborating with the school district to create a field in the school nurse’s EHR or software system to indicate students’ enrollment status in the SBTH program.
Many SBTH programs offer consent form validity for the entire time the student is enrolled in the district, unless revoked. This practice is highly beneficial to accumulating enrollment year after year. Most SBHCs that add telehealth to their program use the same consent form amend it to include this new offering.
Marketing
Collaborate with district leadership early in the implementation process to define the program’s marketing strategy. Develop different flyers and marketing materials depending on the audience. For example, a flyer promoting the program at an elementary school may use different language than a flyer promoting the program at a high school. Consider a printed flyer with a QR code for caregivers to access the electronic consent forms, while an electronic flyer may include a link to access the electronic consent form.
Marketing strategies include working with the district to post consent forms on the district and school websites and social media pages. Students, school nurses, school counselors, school social workers, principals, and caregivers can serve as program champions; providing them with information to share about the program at school and community meetings can leverage support. Provide champions a PowerPoint slide with speaking points and copies of the flyers to use at school meetings and events.
Coordinate with key stakeholders at each participating school and the district leadership to launch the SBTH program. If telehealth is new to the school district, the health center may want partners (see the Partnerships section) to host a press conference announcing the program to the community. Many school districts are eager to share positive news with the community and support awareness of the program. Encourage the SBTH team to participate in school events, sporting events, and community gatherings to promote the program and support enrollment efforts. Bring the telehealth equipment as a strategy to engage with caregivers and students about the program.
Staffing Models
As you build your SBTH team, expect low volumes of student engagement at the beginning of the program implementation. For this reason, leverage existing staffing resources before bringing on additional dedicated SBTH staff. As utilization increases, the Program Manager can hire additional providers and staff to support the program’s volume. Below are four common types of SBTH delivery methods described in Program Models and examples of efficient approaches to staffing providers in your program.
SBTH Model | Brief Description | Staffing Model |
Comprehensive SBHC + Layered Telehealth | An SBHC provides in-person, comprehensive care and enhances specialty care services via telehealth. | Specialists at a health center are available for scheduled visits via telehealth. |
Comprehensive SBHC + Telehealth Network | An SBHC provides in-person, comprehensive care and connects to students at other schools via telehealth. The provider also rotates through the telehealth schools at regular intervals to deliver in-person care. | The provider staffing the SBHC can connect to the satellite telehealth schools. When the provider goes onsite to the satellite schools to deliver care, they are still available to connect to the other schools (including the comprehensive SBHC) for a telehealth visit. |
Telehealth Network + Rotating Onsite Services | A health center connects to schools via telehealth and at regular intervals, provides onsite care.
| The provider has telehealth visits scheduled in between clinic visits at a health center. When the provider goes onsite to the school to deliver care, they are still available to connect to the other schools for a telehealth visit. |
Telehealth Exclusive | Students receive all services remotely. | The provider is available to see SBTH students in between clinic visits at a health center. Another model is that the provider delivers care to students via other telehealth initiatives, such as direct-to-consumer virtual care, between SBTH visits. |
One essential element of the SBTH team is determining who will serve in the telepresenter role. Many programs utilize the school nurse to facilitate the telepresenting process, while others employ a medical assistant or nurse from the health center as telepresenter. Some programs split the role based on the needed level of care; school nurses telepresent acute care visits while SBTH medical assistants or nurses telepresent chronic visits. Arrange the schedule so that several chronic visits are scheduled in the same school and on the same day. This model is most efficient for this staffing scenario as the telepresenter travels to one school to telepresent scheduled visits rather than driving from school to school to support acute visits.
Below are example job descriptions for SBTH team roles from the Medical University of South Carolina:
School-Based Telehealth Medical Director
The School-Based Telehealth (SBTH) Medical Director is responsible for overseeing the School-Based Telehealth clinical operations. The SBTH Medical Director leads the strategy and evaluation efforts for the program and works in close collaboration with the School-Based Health Manager. This role also works with the school nurses, local medical homes, and caregivers to manage the health of children who have consented to the program. This role provides clinical supervision to SBTH medical assistants and nurses.
School-Based Health Manager
The School-Based Health Manager reports to the Director of Operations. Under limited supervision, the School-Based Health Manager oversees the development, implementation, operation, budget, and overall management of a School-Based Telehealth (SBTH) network in rural and underserved communities. This position collaborates with administrative, technical, and clinical staff at the health center, outlying schools, and local providers to manage the administrative components of the program. This role demonstrates an understanding of factors that contribute to a successful SBTH program, including legal, education policies, administrative, technical, and sustainability.
School-Based Telehealth Program Coordinator
The School-Based Telehealth (SBTH) Program Coordinator– reports to the School-Based Health Manager. Under general supervision, the SBTH Coordinator supports and coordinates the development, implementation, and operation of the SBTH program. This position collaborates with administrative, technical, and clinical staff and outlying facilities to promote the coordinated use of resources across multiple specialties and facilities to develop strong relationships between institutions for the advancement of telehealth programs, and to optimize the sustainability and functional efficiency of the SBTH program. The role demonstrates an understanding of factors that contribute to successful telehealth programs, including legal, credentialing, licensing, state and federal policy, administrative, technical, and financial issues.
School-Based Nurse Telepresenter
The School-Based Nurse Telepresenter– reports to the School-Based Health Manager. Under indirect supervision, the Telepresenter utilizes telemedicine equipment (exam camera, otoscope, stethoscope, and video conference) to present the patient to clinicians at the health center or in the local community. This position provides administrative support to the School-Based Telehealth program in assigned locations. This role attends school and community events to promote the program and engage in public health efforts through school and community programing and collaborates with school nurses to identify high-risk students. This position also serves as a care coordinator, which includes directing families to resources such as Medicaid, SNAP, WIC, home energy assistance, and other community assistance programs.
School-Based Telehealth Advanced Practice Provider (APP)
The School-Based Telehealth (SBTH) APP reports to the SBTH Medical Director. The SBTH APP is responsible for the provision of acute illness health care services and chronic disease management for enrolled children at participating school sites. This role collaborates with the school-nurses, local medical homes, and caregivers to manage the health of students who have consented to the program.
Training
Robust training is essential for the program’s success for all SBTH program staff or partnering school staff who make referrals, appointments, or telepresent. Training should include the below elements as part of core competencies:
Role | Training Topics |
School nurses |
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Providers |
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Schedulers |
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SBTH program staff |
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Maintaining a Confidential Experience
Encourage and support telepresenters to maintain a private space as much as possible during a telehealth visit. When the telepresenter is a school nurse, they may ask the front office to “cover” the health suite for while facilitating a telehealth visit. It is also important that—with the student’s and/or caregiver’s consent—SBTH staff and school partners discuss any student findings with other health care provider(s) involved in the student’s care (and is shared only on a need-to-know basis).
Examples from the Field
The below description is modified slightly from the article, “Connecting Kids to Care: Developing a School-Based Telehealth Program.” It outlines the Telehealth Service Implementation Model (TSIM™), created by the Medical University of South Carolina (MUSC) Center for Telehealth to provide a consistent framework for telehealth service development.1 Here is how the TSIMTM can be applied to SBTH program development. The six phases of TSIMTM include pipeline, strategy, development, implementation, operations, and continual quality improvement. Each phase builds upon the previous. Therefore, the SBTH process begins with the pipeline, or requests to develop a new SBTH location initiated by local healthcare providers, schools, or other stakeholders.
Next, during the strategy phase, the SBTH leadership team, school districts, and key stakeholders work to identify common goals and keys to the success of the program in that specific community. This phase includes providing an overview of the program, determining local provider participation, executing agreements, and developing a marketing plan. The first step in the strategy phase is to meet with school district leadership and community stakeholders–such as a local provider group–to present an overview of the program. Note that local providers often have an existing relationship with a school district. The second step includes executing agreements between MUSC, the school district, and local provider group(s). In our example, the MUSC legal team worked closely with the South Carolina (SC) Department of Education legal team to create agreements and consent forms early in the development of the program. The final step, upon approval from district leadership, the SBTH team provides an overview presentation to school nurses, as it is very important to gain their support early on.
During the development phase, a telehealth network engineer connects with the school district information technology (IT) team to complete a thorough IT assessment, ensuring there is a dedicated data port, space for the cart, sufficient bandwidth, and opened firewalls to support the telehealth visits. The telehealth equipment is then ordered. If a local provider group is participating, an IT assessment will also need to be completed for the practice. The only necessary technology on the provider end is a computer, webcam, and headphones with a microphone. There are a few additional business requirements completed in the development phase such as adding the school to the program’s CLIA Waiver to allow POCT onsite, ensuring the EMR is set-up to support the school location and visit type, and developing a consent form distribution plan. Goals and outcomes measures are also defined in this phase.
During the implementation phase, the focus is on educating school nurses and providers and initiating mock calls, which help ensure the equipment is working correctly and that the end-users are comfortable conducting visits. The Lead NP oversees the development and implementation of training and education for the program, including the consent process, technology use, workflow, documentation, billing, POCT training, telehealth etiquette, exam techniques, and communication and care coordination following the encounter. In addition, provider-specific training includes the importance of maintaining standard of care, communicating with the student’s medical home, and reviewing laws on telehealth care. Ongoing support and training are provided along with a comprehensive manual. Following training, mock calls are completed between the school nurse and participating providers. If the mock calls are successful, plans for starting the service are communicated to all stakeholders.
The operation phase focuses on launching the program. Once a school is live, the marketing strategy is implemented, including a range of initiatives to increase awareness and enrollment of the program through student registration, social media, and the school district’s websites. For new SBTH districts, strategies include collaborating with the district to host a press conference announcing the service to the community. Attending back-to-school events, parent meetings, and sporting events are also helpful in building awareness of the program.
Finally, the continual quality improvement phase includes ongoing evaluation of the program and monitoring process measures such as utilization and student enrollment, in addition to key performance indicators such as provider response time. Quality and outcomes measures evolved along with the program.
Garber, K., Wells, E., Hale, K., & King, K. (2021). Connecting Kids to Care: Developing a School-Based Telehealth Program. The Journal for Nurse Practitioners. https://doi.org/10.1016/j.nurpra.2020.12.024