Case Studies

Community Health Center of Branch County - School Tele-health Program

Coldwater, MI

Overview
At the onset of the Community Health Center of Branch County (CHC) School Tele-health Program (the Program), Michigan ranked last in the nation for school nurse per well student ratio, according to the 2010 National Association of School Nurses and Healthy People Guidelines. Education professionals (secretaries, administrators, and teachers) are often responsible for evaluating students for illness, administering medications, and making decisions about students’ health care – an area outside their expertise. Students are absent from school and parents miss work for wellness visits, follow-ups, immunizations, sports physicals, and sick visits. There were no school nurses in the three Branch County school districts prior to the Program. That system created a health care crisis for Branch County youth. Hospitalizations for all ambulatory sensitive conditions (18 years and younger) were 48 percent higher in Branch County than state rates, according to the 2015 Michigan Inpatient Database. Teen pregnancy rates were 17 percent higher than state rates, and the county lacks Title X Family Planning Services. Obesity rates were 36.3 percent compared with 26.1 percent for the state, placing area youth at high risk for chronic conditions. Acute care, disease management, prevention services, and health education were missing from local schools; these statistics demonstrate the negative impact.

As a result of these alarming statistics, the Program was launched in January 2014 as the first school health program to utilize tele-medicine in Michigan. The Program includes three school clinic sites that serve students in sixth through twelfth grade in three school districts throughout Branch County: Bronson Community Schools, Coldwater Community Schools, and Quincy Community Schools. Each school clinic is staffed with a registered nurse. The school clinics are connected via tele-medicine equipment to the CHC Pediatric and Adolescent Clinic (PAC) on the CHC campus. The tele-medicine equipment provides a secure audio/visual connection that transmits high-definition images and sounds to the PAC. Tele-medicine calls are answered by the medical staff at the PAC, which includes four physicians and one nurse practitioner. While working within their scope of practice under the supervision and direction of a medical director, the nurses at the school clinics can provide acute care and chronic disease management; administer medications; complete immunization assessments using Michigan Care Improvement Registry (MCIR); deliver preventative care; provide confidential services (i.e., HIV testing and counseling, STI screenings and treatments, pregnancy testing, etc. in compliance with Michigan’s Minor Consent Law); provide health education on site; and provide referrals to specialty services, follow-up, and care coordination.

The primary goal of the Program is to increase access for adolescent students to preventative and primary health care and health education. The school clinics blend technological efficiencies with an alternative staffing design to improve health care access and outcomes at a fraction of the cost by allowing one provider to cover four clinics from one location. With projected shortages of physicians and mid-level providers, this model provides a safe and efficient connection between the registered nurses at the school and the providers at CHC.

Impact
The Program created school clinics with tele-medicine equipment and staffed with a registered nurse in each high school. The equipment creates a high-speed, secure connection to the PAC. When a student needs more in-depth evaluation, the registered nurse initiates a call with a physician or nurse practitioner at the PAC. The registered nurse communicates with the student’s legal guardian to receive approval for treatment, consent for testing if appropriate, and instructions for treatment and follow-up.

The Program immediately improved the school nurse per well student ratio in Branch County and expanded access to more than 2,700 adolescents. In the first nine months of the Program, 900 students completed enrollment packets – approximately three times the original goal. The school clinics have had more than 1,000 billable visits since January 2016. These outcomes demonstrate the acceptance and support of community members. Youth and parent advisory councils have been formed in each of the three school districts to garner the support and create adolescent-friendly programming. Individuals and local foundations have demonstrated their support by donating more than $320,000.

The clinics administer approximately 1,200 vaccines annually. Of the students vaccinated, 96.3 percent have up-to-date immunization status. Overall, the immunization rate in Branch County has improved from 59 percent to 75 percent since January 2012.

Lessons Learned
A key to the success of the Program was not only the community support, but the support and flexibility demonstrated by the state of Michigan, to modify state Medicaid requirements for tele-health, and by providing the transformational grant that allowed the Program to become established. HRSA also awarded the Program with the Telehealth Network Grant Program that allowed for the continuation and expansion of the tele-health program through 2020.

Where school-based health clinics provide excellent care, some programs have scaled back due to losses incurred by using mid-level or physician providers at school sites. For urban settings, due to the Medicaid “five-mile rule” (distance from a physician office), this model is currently not reimbursable in many states. But with continued, evidence-based progress in rural tele health programs such as the CHC Program, it is hoped that state Medicaid programs will see the value in the cost-effective, efficient care provided through tele-health – not only for students, but for school staff and parents in urban settings, as well. The Community Health Center of Branch County’s School Tele-health Program has proved that a tele-health model can succeed on many levels, as described above, and should be recognized for breaking new ground in the provision of care, while working with the community, health care providers, and local and state agencies.

A reliable tele-health product and connection is key to a high-quality exam. AMD Global Telemedicine Tele-Med ED cart has proved to be an affordable and reliable solution for school-based health. The School Tele-health Program also utilizes wireless and fiber options for connection in case of unexpected downtime.

Future Goals
Future goals of the CHC School Tele-health Program include expansion of tele-health services to include tele-spirometry to better care for asthmatic patients. In addition, the Program will be employing an additional full-time Licensed Master Social Worker and strengthening mental health services by adding a tele-mental health component. Program leaders look to assist in facilitating tele-dentistry by 2019. Lastly, expansion of a fourth clinic will take place in the 2018-2019 school year.

Contact: Kristin Smith, R.N.
Director, Patient Experience
Telephone: 517-279-5006
Email: ksmith@chcbc.com


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