When one thinks about a school health clinic, the image that comes to mind is likely that of a single harried nurse working in a dingy room with dated equipment. But school health centers have been undergoing something of a makeover in recent years, expanding in size and scope. In part, these changes reflect the impact of the $200 million allocated by the Affordable Care Act for school-based health centers. But they also are related to a broader push to focus on the social determinants of health.
In Oregon, where school health advocates have been particularly proactive for the past two decades, the state increased its share of funding for local school clinics from $1.3 million in 2002 to $6.8 million in 2014. “We emphasize that school-based health centers are part of the social safety net, and the number of kids that are in school are the number of kids who have access to health care,” says Sarah Knipper, a school health economist at the Oregon Health Authority.
Across the country, there is still a lot of unmet need for health services in public schools: More than half don’t have even a single full-time nurse. That’s one reason that school-based health centers have been a breeding ground for experimentation in the brave new world of telemedicine.
Underserved rural areas present a special opportunity for telehealth efforts. Before going to medical school, Steve North worked for Teach for America in rural North Carolina, and he was struck by just how much health impacts a child’s ability to come to school and thrive. Now, as medical director of the North Carolina-based Center for Rural Health Innovation, he’s overseen a telehealth program that in six years has grown to 33 schools in the state. In three rural counties, every school now has access to telehealth options. Some urban school districts also have been testing the waters. In the Bronx, where there are 23 school-based health centers but just one school child psychiatrist, telehealth has been used for psychiatric medication management appointments.
But few in the school health community see telehealth as a fix-all for underserved areas, particularly when it comes to preventive care. “My greatest fear is we’re going to buy this equipment and think it’s a replacement for a school nurse,” says John Schlitt, president of the School-Based Health Alliance. “You can do some great things with acute care and mental health, but it’s not a primary care tool.”
North agrees, adding that he’s been getting phone calls from venture capitalists looking to cash in on the innovative technology of telehealth. “Whenever I explain that telehealth must be integrated care focused on the whole child -- care that ultimately helps them reach educational achievement -- that typically ends the conversation.”
That focus on the whole child -- including family and neighborhood factors seen as determinants of health -- is one reason some school clinics have opened their doors to the outside community. North says this marks a changing attitude around school health clinics, which historically haven’t been brought into conversations around healthier communities. North sees school clinics ultimately fitting into a broader “patient-centered community care” model. School clinics, he says, “should be a resource, not a competitor.”