“If you’ve seen one school-based health center, you’ve seen only one school-based health center.”
This phrase perfectly sums up the uniqueness of each school based health center (SBHC) and aptly applies to choosing a model for your own school-based telehealth (SBTH) program. While selecting and defining your model includes several elements and considerations, keep in mind that all SBTH programs encompass three main components: services, delivery method(s), and the SBTH team. The program model builds on your needs assessment outcomes and guides the development of the specific SBTH business plan, technology and equipment selections, implementation approach, and program evaluation.
Before designing a program, reflect on the identified needs and readiness of your stakeholders. To accomplish this task, consider the following questions with your planning group:
- What problem are we trying to solve?
- What is the end goal?
- Is telehealth the answer for all identified needs?
- If not, what is our plan for providing and connecting to in-person care?
- Can our program address every need right now?
- If not, how will we prioritize and/or create a phased-in approach?
- What scope of services will we provide?
- How will we provide each service?
- Will it involve partner providers and organizations?
- Who will serve in each role (e.g., school nurse, NP)?
- Do we need the same positions at each site?
- Will chosen providers deliver telehealth only or in-person care as well?
The following sections offer an array of options and examples for your SBTH program’s services, delivery method(s), and SBTH team members. When determining each component, it is vital to recognize the telehealth opportunities as well as limitations. Whether the reason is a technology failure or a clinical necessity (e.g., a procedure or physical exam), program models should include a plan to refer to in-person care if needed (see Implementation for details). Ideally, layering telehealth will add value within an existing or planned SBHC—one that integrates comprehensive primary and behavioral health care—such as offering expanded services and broader provider availability to ensure continuity of care.
Across clinical and non-clinical care, telehealth services can include prevention, diagnosis, treatment, management, health education, linkages, referrals, and care coordination. While technological advances continue to enhance the breadth of telehealth possibilities, telehealth is not a replacement for traditional care nor appropriate for all services. Below is a sample list of services to consider for inclusion in your SBTH program.
Selecting Delivery Method(s)
In SBTH, the distant site is typically the location of the telehealth providers and the originating site is where the student is during the time of the telehealth visit. In times of remote learning, the originating site may be the student’s home.
There are three common delivery methods for SBTH programs. The following descriptions provide examples for the SBTH team, but are not exhaustive of every possibility. As you plan your SBTH program, weigh the benefits and considerations (i.e. separate providers versus one provider for in-person and telehealth) before selecting the delivery method that best aligns with your capacity and sustainability plans.
There are three common types of SBTH delivery methods:
- Comprehensive SBHC + Telehealth
- Comprehensive SBHC + Hybrid Telehealth: model, a health center sponsors an SBHC at a fixed location in a school or on a school campus. Students can access in-person comprehensive care from physically onsite providers and receive specialty care services via telehealth from a distant site.
- Comprehensive SBHC + Telehealth Network: model, a health center sponsors an SBHC at a fixed location in a school or on a school campus and provides in-person comprehensive care to students in that school. To expand access, the provider delivers care via telehealth (distant site) to students at other satellite schools (originating sites). An SBHC provider rotates through the satellite schools at regular intervals, delivering in-person preventive care. When the provider is at the satellite schools, they can act as the distant site, delivering telehealth care to the comprehensive SBHC or another satellite school (originating sites).
- Telehealth Network + Rotating Onsite Services: A health center does not sponsor a traditional, onsite SBHC. Instead, the health center provides telehealth care to one or more schools, with the health center as the distant site and the school(s) as the originating site(s). The SBTH visits are assigned alongside provider(s)’ health center appointment(s). Health center provider(s) also regularly rotate through the school(s), delivering in-person preventive care. When a provider is onsite at a school (distant site) in a rural area and availability allows, they may deliver care via telehealth to other participating school(s) (originating site(s)).
- Telehealth Exclusive: Students access care at a fixed location (originating site) on a school campus (typically the school nurse’s office), and providers are available remotely (distant site) for all services.
In each of these SBTH programs, the health center sponsor must develop business agreements outlining scopes of services, responsibilities of all parties, bi-directional communication practices, and care coordination to ensure students’ access to in-person care, when necessary. Students may access this care at the sponsor’s health center sites, an SBHC, via rotating school visits, or by visits to their chosen primary care provider.
Creating the SBTH Team
A successful SBTH program requires a skilled and dedicated team to operate the program efficiently and effectively. How you assign roles among school-based health care professionals and school staff, community agencies, or other health providers, depends on the structure of your organization, services, delivery method, and the number of provider partners involved. For example, in telehealth exclusive models, the sponsoring health center that manages the distant site(s) is typically responsible for the operations and logistics. These include, but are not limited to:
- Managing clinical staff;
- Coordinating with partnering schools;
- Purchasing and maintaining equipment (which is stored at the school site);
- Identifying staff, training staff and school personnel on the proper use of equipment to facilitate telehealth encounters, complying with security regulations;
- Billing for services as appropriate and available; and
- Ensuring continuity of care for students seen at the school sites.
Conversely, partnering schools typically oversee:
- Housing the telehealth equipment (not unlike traditional SBHCs that provide space for facilities);
- Providing broadband Internet connection and ensuring the appropriate firewalls are opened to support a successful telehealth visit; and
- Providing space in the school for telehealth visits.
Consider the following roles and functions as you build your SBTH team. While one person may serve multiple positions, think about the benefits and trade-offs for each role when the position is run by health center staff versus school staff.
Program Manager: manages the operational and administrative components of the telehealth program including—but not limited to—executing agreements with school districts, communicating with school district leaders, facilitating needs assessment, creating policy and procedures, overseeing the budget, creating reports highlighting utilization and enrollment, developing workflows, and managing staff.
Program Coordinator: responsible for the day-to-day coordination and the primary telehealth contact for families and schools. Facilitates staff and school nurse training, oversees scheduling workflow, conducts marketing, and supports enrollment efforts. The coordinator is also responsible for ensuring equipment and connectivity are working at each school site.
Telepresenter: supports the telehealth visit before (e.g., confirms student need, ensures student consent form is on file, calls the parent to gather pertinent medical information, and requests telehealth visit from the provider), during (e.g., operates the telehealth equipment to “present” the student to the consulting provider), and after (e.g., ensures the student and/or family is contacted with the plan of care, completes any paperwork required for billing). A health center employee, school nurse, health tech, other school employee, or a combination of these, serves in the telepresenter role.
Providers: located at a distant site and connects with telepresenter to provide services during the designated hours. Responsible for leading and conducting the actual student interaction as well as directing the actions of those assisting the student. Follows-up with the student and/or student’s family with the plan of care and sends a note to the student’s primary care provider about the visit.
IT Staff: installs telehealth technology and provides ongoing support for telehealth equipment, software, and internet connectivity as needed. The health system IT staff collaborates closely with the school district IT staff to ensure the telehealth equipment can function on the school district’s network. Additionally, it is important for this role to include being available to support equipment trouble shooting during a telehealth encounter.
Medical/Clinical Director: directs the clinical and operational components of the program. This position often serves as the program champion, providing direction, and overseeing the strategy and clinical oversight of the SBTH program. The director works closely with the program manager and telehealth coordinator.
Examples from the Field
La Clínica de La Raza – Oakland, California
Telehealth Services: primary care, sexual health, behavioral health, health education
Like many health center programs, La Clínica de La Raza in CA quickly adapted their SBHCs to offer telehealth amid school closures due to the pandemic. With a focus on care continuity for East Bay students ages 3-24, SBHC staff (front desk, MA, medical providers, integrated behavioral health clinicians, and Americorps Health Educators) all play a part in connecting students to telehealth services. While five of their eight school-based sites are closed, La Clínica facilitates as many telehealth visits as possible, providing medical and psychosocial assessments, answering medical questions, providing anticipatory guidance, and sending medication refills to pharmacies. Most importantly, they check in with how students are managing during shelter in place and distance learning, and how they can support students’ overall well-being. They also coordinate appointments at their three community-linked school-based health centers for needs requiring in-person care. On the day of a scheduled telehealth visit, the student checks in with the MA for ‘virtual rooming,’ where they either meet with the clinician immediately or receive a call back at a designated time. The clinician then conducts the visit via telephone, and if needed, transfers the student to the front desk personnel to schedule a follow-up visit via telehealth (or in-person for vaccinations, labs, procedures, or physical exams). La Clínica behavioral health providers offer the option of video visits to their patients, and they hope to expand to medical video visits soon.
Shalom Health Care Center – Indianapolis, Indiana
Telehealth Services: primary care, behavioral health
Shalom Health Care Center’s school-based health care program consists of 28 SBHCs throughout Indianapolis, serving students in K-12. With the urgency of providing health care amidst COVID-19, Shalom Health Care Center quickly developed a school-based telehealth program to complement their SBHCs. Their SBTH program utilizes nurse practitioners to deliver primary care through videoconferencing. In light of the pandemic, the SBHC staff encourage students to meet a provider via telehealth from home before coming into school to discuss any COVID or non-COVID related needs. A few of the system’s SBHC sites are open and operate a hybrid care model where students can access care virtually or in-person even if their school is closed. With the addition of telehealth, Shalom Health Care Center conducts community outreach to students and families, educating them on how to use the patient portal to access their health information and schedule appointments.
“Define & Specify Program Model” using California TRC’s Telehealth Program Developer Kit
- Telehealth Program Developer: Define & Specify Program Model
- Telehealth Program Developer: Define & Specify Program Model Checklist
- Telehealth Program Developer: Program Charter Template