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Caitlin Whyte: Since 2014, the school-based telehealth program at Children's Health has provided more than 12,000 virtual health visits for students expanded into 185 schools and 25 school districts and counting, and achieved a 94% satisfaction rate from parents. Additionally in 2017, a tele behavioral health component was added, which connects children who may be struggling with emotional stress with a therapist or counselor virtually. The telehealth component is now used by 21 public school districts and two private schools. Today, we're going to talk about how the program got started, the benefits of these school-based services and how schools and providers can learn more. Joining us today are Karen Kaighan, the Director of School Health Programs at Children's Health and Jason Isham, the Director of the Integrated Behavioral Health program at Children's Health. This is Pediatric Insights, advances, and innovations with Children's Health. I'm your host, Caitlin Whyte. First, can you explain what school-based telehealth and tele behavioral health is for those who may not know? Jason, let's start with you.

Jason Isham: Sure. So, I'll cover the tele behavioral health piece. Tele behavioral health is an opportunity to provide rapid access to behavioral health services for students in schools using virtual telemedicine technology. In this case, it's a tablet device with a video conferencing application. And in that way, the students at school or at home can connect with our clinicians here at children's health via that tablet and via that video conferencing application.

Karen Kaighan: And our school-based telehealth program is a medical delivery model, in which we use technology, which is a cart or an iPad that is used to exchange medical information from one site to another. There's many different formats, but we use the video technology with diagnostic devices, which includes a stethoscope, an otoscope, and a dermoscope, but the child can see a pediatric nurse practitioner or a pediatrician while at school, from the school nurse office.

Host: And Karen, can you walk us through the history of the programs and how they began? I mean, what did it take to establish these programs and what were some of the hurdles?

Karen Kaighan: The school program started in 2014 under the leadership of Julie Hall Barrow. She came from Arkansas and had done a lot of work in the telestroke area. We started at Children's Health within our CHPG clinic. Our pediatrician Dr. Stormy Williams had completed her residency at Children's Health, and was the first physician who implemented the program in that the CHPG clinic. It was a little bit difficult at first, she was seeing patients in the traditional clinic setting. And then we were adding patients to her schedule using telehealth. At the time the telehealth equipment had been placed in a daycare setting. So while she was seeing patients in the clinic, and we would overlay the opportunity to see daycare children using the telehealth equipment, which kind of made it confusing with double booking. And then also just in the face of, in the daycare that we realized quickly that, of course, when the child is sick, you know, the typical response is for a parent to pick them up.

But more importantly, we could see that the child had a hard time expressing their medical concern to the provider. As a result of that, we pivoted from daycare setting to go into the school settings. We had established telehealth and the school based on the fact that, of course, as a pediatric institution, we're here to take care of kids. That's our fundamental population and has been, and will continue to be. So we focused into the school setting. And as a result, we've grown into the 185 schools and are continuing to grow some of the hurdles that we had early on. We're working with physician groups locally, and then up to the legislative level to allow a provider, to see a patient, even if it wasn't the PCP or the primary care physician on record, but kind of establish the opportunity to see a patient remotely using telehealth. Senate Bill 1107 supported this, and we were working diligently to, to advocate for that piece of legislation.

In addition, another hurdle that we actually also overcame was passing of Senate Bill 670, which assisted in increasing virtual access to care for our Medicaid recipients. We see a variety of patients at Children's Health, but we do know that that is one of our larger population. So those are some of these larger hurdles, of course, in bringing it down to our metroplex and where we are now, currently in our schools, we work and navigate through local school district and charter school system policies and procedures, and then drilling it down, even into the base of how we operate. We work with a variety of nurses with all different types of clinical backgrounds and the way that they operate their school clinics. So those have been less challenging as the program has continued to grow. And the nurses of course share information, you know, from their own clinics, through their teams. And then of course, you know, with other school districts.

Jason Isham: So, for the tele behavioral health program as Karen mentioned until her program grew very, very rapidly. And it was very well received by our local school districts here in North Texas. And as a result of that, with their positive response to the program, they began asking Karen and her team, you know, we love this program a lot, but what can you all do in terms of a behavioral health solution? And so Karen and her leadership began a conversation with the behavioral health leadership at children's at the time. And we'd been doing behavior health care in primary care pediatric practices, whereby we would assign licensed masters level clinicians to pediatric practices to help identify and treat behavioral health needs of patients there. And so, you know, we began to dream and vision of what it would be like if we were to add or move that model from the clinic space into a school setting. And so rather than getting referral from a pediatrician or a nurse practitioner, what if that referral came from a school counselor? And so we actually launched that idea here locally in Carrollton Farmers Branch ISD in the fall of 2017, its five campuses.

And currently this fall, we will be in over 170 campuses throughout North Texas. And so again, there's been a tremendous response to the program and to the idea of leveraging both technology to provide access to care. And then also providing that access in a school setting. We were fortunate with behavioral health because Texas had been an early adopter of behavioral health telemedicine through our local mental health authorities. Because Texas is such a large state, the legislature had really paved the way for behavioral health to be able to utilize telehealth as a modality. And so we were able to leverage that and get the program up and running much more quickly. I think the biggest hurdle for us in the tele behavioral health program is to make sure that we're realizing that we're asking school counselors and school administrators to behave differently, to really alter their daily habits and their daily routines in order to consider how to implement a school based tele behavioral health program into their daily workflow and into their school and campus life. And so, as we've continued to support that over time, again, like Karen, we continue to see greater and greater response and receptiveness to the program and to the idea

Host: Now, Jason, can you walk us through the steps that the healthcare providers and the schools go through from start to finish for one of these appointments?

Jason Isham: So, in terms of the virtual visit itself, there are really three steps to the process, both on the telehealth side and on the tellers, the behavioral side. And the first step is that the patient family and the patient need to be consented into the program. And so, Karen and I are programmed to do that a little bit differently, but the bottom line is that the schools will assist with making sure that the student and the parents guardian have informed consent for that student to participate either in the telehealth program or the tele behavioral health program. And we do that in a variety of different ways. We have online registration enrollment through the school and the districts registration process at the beginning of school for new and returning students. And we also do that on a one off basis through an online consenting process through our children's.com websites. And then we also will work directly with counselors and student families to provide consents and the consenting process to them via paper process, if they have technological challenges and aren't able to access those online opportunities.

And so really, we want to tailor that process to the needs of the schools and then also to the parents. The second phase of the virtual visit process is the actual appointment itself. And here there's a little bit of a difference between the telehealth model and the tele behavioral health and telehealth. It requires what's called a tele presenter, which means that there needs to be someone with the patient to present the appointment to the clinician or the pediatrician who is seeing that patient. In this case in Karen's program, it's a school nurse that is that tele presenter, and they really become the hands and the feet of the pediatrician remotely. So they are able to utilize the instruments that Karen talk about here in a moment, and they will help the physician do the remote virtual exam by being that tele presenter. On the other hand, with tele behavioral health, we're able to have a one to one relationship with the students. And so there's no need for a tele presenter in behavioral health. And so it's really just a matter of connecting on that student with behavioral health clinician via the video conferencing app.

And so again, we just need to make sure that we have appropriate internet technology so that we can establish a secure connection. And then once we have that, then we're able to do that through our video conferencing app and the tablet device. And then the last phase is sort of the follow-up piece. And so again, there's some differences in telehealth and tele behavioral health and telehealth, they provide what's called an after-visit summary, which is standard practice in pediatric medicine. And really healthcare in general that will summarize the visit. Karen's team of pediatricians and nurse practitioners also have the ability to do e-prescriptions for students that need that through the tele-health modality. And so that way, when students leave the campus, they have a prescription waiting for them at the pharmacy. And parents can pick that up on the way home from work and make that very, very convenient. And for behavioral health, really, for us, it following up with the counselor that made the referral and with the parents to update them about the student's progress in the virtual therapy sessions, to make sure that everyone is sort of in the loop. And we're all working in the same direction to make life better for that child.

Host: Now with this new remote world, Karen, let's talk about equipment, what is used for these exams and why is it important for the program success?

Karen Kaighan: Great question. So let's just start by letting everybody know that children's health provides the technology, the training, and we also offer point of care testing as part of the program to schools at no cost. That's one of the first benefits for our school partners. And of course, for us at children's health, we believe in our schools, we believe in the health of our students. And so we believe in expanding our services to students where they are, but to do the actual exam, we provide the technology. As I mentioned, with the stripping flu for the nurse to run a center school clinic. But the thing that makes our equipment better versus our competitors or other telehealth programs out there is that we provide scopes that are attached to the technology. Each of the pieces of technology in each school clinic has a stethoscope to listen to heart and lung sounds, an otoscope to look in the ears, throat, and a dermoscope, which is just a light to look at skin issues.

It can highlight things on the skin and the scalp. We've seen that by using the scopes, of course, for the providers, they have a clear picture. They can see and hear the sounds and see through the technology. And they can also take a still frame picture and add it to the patient's medical chart, even while the child's at school. So in order for the nurse to conduct the exam, we are for HERPA and HIPAA compliant for the nurse to do the exam so that no one else is in the room. And the technology just keeps getting better and better. Currently, what that looks like is an iPad with these scopes attached to it. It's a smaller footprint that we started the program with, and it's also mobile if necessary to move in the clinic for the nurse.

Host: And what are the benefits Karen, of these programs for the schools, the healthcare providers, and the student and their family?

Karen Kaighan: So, the biggest convenience is the biggest factor for family. We know many times parents can't leave work to take their child to the doctor. We also know that the child stays home for a few days, many times before they can even get into the doctor, whether their doctor is full based on the season. If it's flu season, it takes even longer sometimes to get in to see their primary care physician. And back to the fact that families just don't have opportunities to just pick their child up and go straight to the doctor. So we work with our school to make sure, you know, that convenience is at the top most priority for the child and for the nurse to see the child in school. It starts, as Jason said, with his program, we start with a consent form. So the way we've operated this is to have the parent fill a consent form out online, or we added as part of their child's reenrollment process within the school district each year, once the child is consented, then they are, the nurse can go ahead and make the appointment.

The parent is always welcome to come to the school, but the parent does not need to be there, especially if the parent's at work. We also follow the guidelines for the school. Meaning if the child is sick, that the child meets the exclusion criteria for the school district, the parent does need to pick them up, but we also can identify sickness within each classroom. We can track that, the nurse can track that if there's an outbreak of something in the school. In addition to following that, if the child is seen at school, through our telehealth program, many times they don't necessarily need to leave. If it's something that's not contagious. They're not running a fever. They're not meeting the exclusion criteria, yet they have the opportunity to see a physician from the school clinic. We e-prescribe an antibiotic or antiviral illness, if there's the flu, to their pharmacy on file, where mom can pick it up or dad or the guardian can pick it up after school is over, if the child continues to stay at school, and start that medication sooner. In addition to that, it helps us expand, of course, our network, where we're reaching kids, where they are, and that's where they need to be is in school learning.

Host: Now, how have you engaged with schools in order to get this program implemented for students and their families? Jason, tell us a bit more?

Jason Isham: The big picture there is that we look at engagement on multiple levels. And so when we are thinking about a school district and engaging them in one of these programs, we look at how can we engage that school district, both at the school board and trustee level with our government relations team. We also look at how we might engage with the superintendents and the assistant superintendents at the sort of administrative level. And then Karen and I spend a lot of time in conversation with district level staff. So executive directors and director level folks over counseling and nursing, to make sure that they understand the program and what the implications will be for their district. In addition to that, we also then look at how we might partner with the individual campuses and the nurses and the counselors and the administrators on those campuses, so that they, again, they are all in alignment with bringing the program onboard and then making sure that we have a successful implementation and go forward plan. And so what we have found is that when we have that engagement at all of those different levels, then those are the campuses and the districts where we have the most success year over year, and the program continues to grow and meet the needs of those students in those districts.

Additionally, I think the other thing that we have done, which is unique is we've really adopted a partner mindset. And so we want to come alongside the school districts and be a resource for them. We want to help them identify the needs of their student population that we might be able to help address. So for example, we provide education around behavioral health topics for both staff and parents. We also do educational topics around medical topics as well. In addition, we provide collateral material, marketing materials, educational, informational brochures, and flyers. I know Karen also leads a school nursing conference every year for school nurses. Again, we're able to help come alongside that district and help them identify what their needs are. And then we help to meet those needs. We also do specialized services. And so Karen and her team were able to identify world renowned experts in a variety of different fields that are able to really come alongside those districts and provide the resources that they need. And so, you know, we were talking about how, you know, what are the benefits of using Children's Health, and it's exactly that you get access to the whole children's health system and everything that comes with that.

Host: And tell us, Jason, what the benefit of children using a virtual consultation or appointment that Children's Health offers versus using one provided by a different company, right?

Jason Isham: There are a couple of things. One in our school based behavioral health program. Currently at this point in time, we've been able to work with our children's health foundation to secure funding, both at the state level, through a program called the Texas Child Health Access to Telemedicine or Teach at Program. And we also have additional philanthropic funds to provide the school based tele behavioral health program at no cost to districts or students. That is certainly one benefit there. In addition to that, as I mentioned previously, when schools and families, our children's health tele behavioral health or telehealth programs, they're really linking with the greater children's health system. And so they'll have the benefit of all of the resources of Children's Health. World-class specialists with our relationship with UC Southwestern, advanced technology, and network of medical and behavioral health providers across North Texas and beyond. Additionally, we're also able to really act as a connecting piece to many of those services that families might need it. In addition to the virtual visit that they take advantage of with our school based health, behavioral, or telehealth program.

Karen Kaighan: I would just like to add some more additional resources as Jason has given many examples. And this is what sets our programs apart from others is that, of course we're nationally ranked pediatric healthcare institution. So, when we see this child at school for a tele behavioral issue or clinical issue through our school mental health program, that parent has access to our physicians 24/7, there's a support team ready for them. If there's additional questions, after school hours on the weekend, it's a 24/7, 365 operation. We want to take care of our families and we do take care of our families and we do take care of our families well. We want to continue that with expanding ourselves in this community space so that families know that we're here to support them where they live, work, and play. That also ties into, as Jason alluded to and mentioned several of our resources within our clinical spaces, complex care, our ask the management team, our Get Up and Go program, some of specially service areas that continue to support students and family for ongoing care.

Host: And Karen, if a school is interested in implementing this program, how can they get more information? What's the cost to them?

Karen Kaighan: They can find any of our services on our website at children's.com and specifically, if they have tele-health questions, they can reach out to Jason Isham or myself or tele-health behavioral health or school tele-health issues. We're always happy to talk to interested partners about the program to community organizations, leadership groups, civic opportunities, and groups that support their communities. Many of our folks in our community aren't fully aware of the variety of services that Children Health can provide to their family. So they are welcome to find us on our website.

Host: Is there anything else either of you would like to add?

Karen Kaighan: You know, now more than ever as families grapple with trying to make decisions for their students themselves, returning back to school, we are here to support what their needs are. We support our schools, we support our children and our families. If they ever have any questions, please let us know and reach out and we'll be happy to address any of those concerns.

Jason Isham: Yeah. So I think the last thing I would say is, again, I think during this COVID-19 pandemic response, healthcare has really seen the value of telemedicine, tele-health, virtual care, being able to provide care when it's clinically appropriate to patients and the safety and the convenience of their own homes and in a way that that makes sense for them. And so again, I would just encourage those providers there that are contemplating using telemedicine and tele-health to investigate it. There are wonderful associations and training programs that are out there that will help educate providers about how to do telemedicine and do it well. There certainly are some additional considerations that providers will need to think about as they contemplate employing telemedicine in terms of consenting and translating the in-person appointment into a virtual appointment. But there are resources out there. The American telemedicine association is a great one. It's a great place to start, but I would just encourage everyone to think through how can we continue to provide greater access to healthcare for those patients and families that need it.

Host: Well, thank you both so much for your time and for sharing this vital information with us. You can find more information about what we discussed today at childrens.com/telehealth. This has been Pediatric Insights. I'm your host, Caitlin Whyte. Thanks for joining us.