By Michael Booth
The Arnold family had just gotten on top of anxiety issues disrupting the happiness of their two children, ages 10 and 7, and were “weaning” away from their beloved school-based counselors, when COVID-19 hit.
For a 7-year-old nervously clinging to routine for solace, a sudden dictum that school won’t meet for the rest of the year because of a dangerous virus is one of the biggest blows imaginable.
“One of the big triggers for my daughter is change,” said mother Tanya Arnold, “so we immediately saw things start to spiral.”
The Arnolds, who live in Lakewood and choice into a Denver Public School, quickly placed a call to the school. Familiar voices from the staff of the school-based health clinics, run by Denver Health in two locations now with clinic access outdoors or by telehealth, set both Arnold children up on a regular counseling schedule with the woman who had already led them to big personal gains. Now, while their world is shut down, the kids look forward to a regular call and hand each other the phone when their part of the session is done.
“The fact this is available to students is just amazing,” Tanya Arnold said.
The coronavirus crisis has spotlighted the ability of many larger school districts to immediately pivot to telehealth replacement of vital school-based health services, reflecting similar progress-by-necessity in private systems like UCHealth and Kaiser Permanente Colorado. And in less-populated regions of Colorado, shuttered school-based clinics are sending homebound students to community health clinics to replace their services. In a few rare cases, school clinics with outside entrances or other special arrangements have stayed open even while students are shut out of classrooms indefinitely.
Why the scramble to preserve school-based health? Because Colorado’s system of 52 school-based health centers has grown into a crucial element of overall population health, delivering more than 100,000 visits last school year, with the great majority through Medicaid, CHP+ or to uninsured families. School-based clinics in Denver alone signed up more than 4,000 students to insurance plans for the first time last year, according to clinic officials—work that continues even during stay-at-home orders.
“We have 12,000 to 13,000 kids we serve. We knew instantly we would need to find a way to continue services. That was never in doubt,” said Jennifer Koch, director of Denver Health's integrated behavioral health services at school-based clinics.
“They are such a nice one-stop for kids,” said Deidre Johnson, executive director of Denver’s Center for African American Health. (Johnson is a former Colorado Trust employee.) Johnson said she knows of many students who go to their school clinic for a physical ailment, but then make a mental health appointment because it feels private and safe.
“They are really an important part of our system to increase access to care,” Johnson said. “They already have a certain level of trust, so I’m glad they’re able to continue that connection,” despite the COVID-19 pandemic.
Just as they have in extending food services and distributing computers and internet connectivity for distance learning, Colorado school districts have had to cram years of adaptation in school-based health into a few weeks, after closures and social distancing rules went into effect, said Aubrey Hill, executive director of the Colorado Association for School-Based Health Care.
School districts not fully equipped for telehealth have been resorting to tactics like splitting hours at their clinics, to see physically healthy kids in the mornings—for medication refills or ongoing counseling, for example—and kids with physical symptoms in the afternoons, Hill said. Some have even instituted a parking-lot triage system, asking families to wait in their cars and coming out to see them there.
Some clinics are using the pandemic’s push to modernize more quickly. “Most of them before did not offer telehealth services,” Hill said. “This has forced them [to start doing so]; it’s been really great to update and continue the health care services for kids and families.”
In Fort Collins, Merry Hummell, who directs various programs at two area schools and coordinates school-based clinics in northern Colorado for Every Child Pediatrics, talked about the continuity of mental health as a key goal during the pandemic. She mentioned a counseling client she called Marc (not his real name, to protect his privacy).
Haunted by a history of family violence, poverty, substance abuse and severe depression, 19-year-old Marc's behavior had been challenging to some of his teachers, and he also had experienced discrimination in the health care system while seeking to transition to his male identity. He transferred to an alternative high school to finally earn his degree, and tried the school-based health clinic operated by Every Child Pediatrics.
Marc had found the right place. The school clinic offered on-site appointments for his physical problems and mental health issues, cleared away insurance tangles, and even used the right gender pronouns, Hummell said—every time.
When COVID-19 hit Colorado and closed all the school districts, Marc’s care at one of Colorado’s school-based clinics could have been another casualty. Yet Marc has been able to continue his counseling by telephone, with the same trusted school-based therapist, and can check in on any physical questions as well.
“Folks who are different in any way, shape or form, when they find a connection to someone who cares about them individually and knows what the struggles are, the continuity of being able to work with that individual makes an enormous difference,” said Hummell. “One person’s acceptance of you as the human being you are can be life-transforming.”
Every Child Pediatrics had to close its high school health center in Fort Collins when the district closed. The health center staff has been looking up the emails of each student, to send them a direct message to let them know that they still have access to services by phone, and will add in a parent email blast if they are given permission.
“Many of the kids we serve come to school because school is their safe place, they get fed, they have an understanding person who treats them with respect and dignity,” Hummell said.
The clinic was also running a mobile health center at the curb of Lincoln Middle School on the north side of Fort Collins, originally donated by Ronald McDonald House Charities. That had to close as well, though Hummell is now working hard at getting permission to reopen it in coming weeks.
The mobile health center is staffed with a medical assistant, who can do patient intakes and then connect them to remotely-based Every Child Pediatrics providers over a video connection in the trailer. The assistant takes vital signs and can wield a remote stethoscope or otoscope—which providers report give an even better view than using the tools in-person, Hummell said.
Hummell agrees with leaders of other Colorado health systems who say the switch to telehealth is not going away when COVID-19 restrictions are lifted. (Some of the funding for school-based clinics may go away, though; children's health advocates are bracing for proposed funding cuts because of the state's expected large budget shortfalls.) Having a clinic at school for busy kids and busy parents is one move toward convenience, she said, and telehealth is another step above that.
“We set up systems that are accessible as quickly as we can, to set up the best care that we can,” Hummell said.
While Denver Health’s school-based clinic staff is busy reaching out to asthmatic students in their registry, for example, and refilling their inhalers, as well as making behavioral health phone calls, they don’t want parents to assume they can’t take on new students or problems.
“We are still getting referrals for new clients, but it’s fallen off,” Koch of Denver Health said. “We want to let people know we are still available.”