Pediatric Annals

CME 

Improving Access to Care Through the Patient-Centered Medical Home

Stephen W. North, MD, MPH; James McElligot, MD, MSCR; Gaye Douglas, DNP; Amanda Martin, BA

Abstract

School-based health centers (SBHCs) serve an essential role in providing access to high-quality, comprehensive care to underserved children and adolescents in more than 2,000 schools across the United States. SBHCs are an essential component of the health care safety net, and their role in the patient-centered medical home (PCMH) continues to evolve as both collaborating partners and, when fully functioning, independent PCMHs. The American Academy of Pediatrics (AAP) supports the use of SBHCs, citing the proven benefits and exciting potential as justification, but also offers caution and recommends a focus on communication within the community. Traditional “brick and mortar” SBHCs are more likely to be located in urban communities (54.2% urban versus 18.0% rural) and be in schools with more students, allowing for a greater return on investment. Current SBHCs are located in schools with an average population of 997 students. The need for a large school population to help an SBHC approach financial viability excludes children in rural communities who are more likely to attend a school with fewer than 500 students, be poor, and have difficulty accessing health care.

The expansion of telehealth technologies allows the creation of solutions to decrease geographic barriers that have limited the growth of SBHCs in rural communities. Telehealth school-based health centers (tSBHCs) that exclusively provide services through telemedicine are operating and developing in communities where geographic barriers and financial challenges have prevented the establishment of brick and mortar SBHCs. TSBHCs are beginning to increase the number and variety of services they provide through the use of telehealth to include behavioral health, nutrition services, and pediatric specialists. Understanding the role of tSBHCs in the growth of the PCMH model is critical for using these tools to continue to improve child and adolescent health.

Abstract

School-based health centers (SBHCs) serve an essential role in providing access to high-quality, comprehensive care to underserved children and adolescents in more than 2,000 schools across the United States. SBHCs are an essential component of the health care safety net, and their role in the patient-centered medical home (PCMH) continues to evolve as both collaborating partners and, when fully functioning, independent PCMHs. The American Academy of Pediatrics (AAP) supports the use of SBHCs, citing the proven benefits and exciting potential as justification, but also offers caution and recommends a focus on communication within the community. Traditional “brick and mortar” SBHCs are more likely to be located in urban communities (54.2% urban versus 18.0% rural) and be in schools with more students, allowing for a greater return on investment. Current SBHCs are located in schools with an average population of 997 students. The need for a large school population to help an SBHC approach financial viability excludes children in rural communities who are more likely to attend a school with fewer than 500 students, be poor, and have difficulty accessing health care.

The expansion of telehealth technologies allows the creation of solutions to decrease geographic barriers that have limited the growth of SBHCs in rural communities. Telehealth school-based health centers (tSBHCs) that exclusively provide services through telemedicine are operating and developing in communities where geographic barriers and financial challenges have prevented the establishment of brick and mortar SBHCs. TSBHCs are beginning to increase the number and variety of services they provide through the use of telehealth to include behavioral health, nutrition services, and pediatric specialists. Understanding the role of tSBHCs in the growth of the PCMH model is critical for using these tools to continue to improve child and adolescent health.

School-based health centers (SBHCs) serve an essential role in providing access to high-quality, comprehensive care to underserved children and adolescents in more than 2,000 schools across the United States. SBHCs are an essential component of the health care safety net, and their role in the patient-centered medical home (PCMH) continues to evolve as both collaborating partners and, when fully functioning, independent PCMHs. The American Academy of Pediatrics (AAP) supports the use of SBHCs, citing the proven benefits and exciting potential as justification, but also offers caution and recommends a focus on communication within the community.1 Traditional “brick and mortar” SBHCs are more likely to be located in urban communities (54.2% urban versus 18.0% rural) and be in schools with more students, allowing for a greater return on investment. Current SBHCs are located in schools with an average population of 997 students. The need for a large school population to help an SBHC approach financial viability excludes children in rural communities who are more likely to attend a school with fewer than 500 students, be poor, and have difficulty accessing health care.2

The expansion of telehealth technologies allows the creation of solutions to decrease geographic barriers that have limited the growth of SBHCs in rural communities. Telehealth school-based health centers (tSBHCs) that exclusively provide services through telemedicine are operating and developing in communities where geographic barriers and financial challenges have prevented the establishment of brick and mortar SBHCs. TSBHCs are beginning to increase the number and variety of services they provide through the use of telehealth to include behavioral health, nutrition services, and pediatric specialists (Table 1). Additionally, existing SBHCs are beginning to expand their hours and their scope of services using telehealth technologies. Understanding the role of tSBHCs in the growth of the PCMH model is critical for using these tools to continue to improve child and adolescent health.

TeleSchool-Based Health Center Models

Table 1.

TeleSchool-Based Health Center Models

During a school-based telehealth encounter, teleconferencing technology connects a school with not only the primary care provider (PCP), but also potentially a wide variety of health providers, allowing comprehensive care from the convenience of the school. Operation of a tSBHC follows many of the same standards as a traditional SBHC. For each student, parents enroll the student in the tSBHC prior to the visit, providing medical history information and the name of the PCP. Visits for students can be scheduled by parents, teachers, the school nurse, or a health care provider. Following each visit, the tSBHC provider communicates with the child’s parent or guardian and sends a copy of the office note to the PCP.

SBHCs began in the 1980s, often funded through Title X reproductive health programs. The 2010–2011 School-Based Health Alliance (formerly the National Assembly on School-Based Health Care) Census documented 1,930 SBHCs in the United States.3 A growing body of evidence illustrates that SBHCs have distinct impact on the health and academic benefits of their patients. SBHCs have been shown to provide the same quality of adolescent preventive health care as traditional primary care sites,4 and improvements in health outcomes include: improved access to preventive health care and decreased emergency department use,5–7 improved student utilization of mental health services,8 improved academic outcomes for high-risk adolescents,9 and decreased likelihood of dropping out of high school in both the general population10 and expectant young mothers.11

School-based telehealth programs are relatively new in the scope of school-based health care, with one of the first programs starting in 1996 in Hart, Texas.12 School-based telehealth programs either provide additional services at an existing SBHC or provide all services via telehealth. Growing evidence supports that this delivery mechanism improves access to care and decreases stresses on families.13 In an early study, the use of school-based telehealth prevented a parent or guardian from missing an average of 3.4 hours of work time and saved approximately $101 to $224 for each visit.14 The Center for Rural Health Innovation’s surveys of school-based telehealth programs has identified 24 operating programs and 24 programs currently in the planning stage.15

The Affordable Care Act16 included capital funding for school-based health care, and 520 unique programs received a total of $189,935,418.17 In many communities these funds are being used to develop and expand school-based telehealth. Understanding how school-based telehealth programs can collaborate with the primary care medical home is critical in establishing their value and demonstrating their ability to provide high-quality health care for children in underserved communities.

A Personal Provider

The personal physician is one of the key components of the Joint Principles of the PCMH and is described as “each patient [having] ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.”18 The function of this principle within primary care is to deliver a sustained partnership between the patient and provider, and the attempts at quantifying this element relate to measurements of access and communication.19 When integrated within the local health care community, school-based care is well-positioned to address this principle, and the application of telehealth further augments this capability. Some providers may choose to participate in telehealth school-based programs directly with an office-to-school connection. This allows the provider to extend the reach of their practice without sacrificing efficiency. Other providers may see the benefit of a strong relationship with the program and partner to provide coordinated and continuous care to otherwise underserved children. Lastly, establishing telehealth in the school setting enhances the ability of PCPs to refer their patients to specialty and ancillary services such as mental health, nutrition, speech therapy, and pulmonary specialists.

Establishing one’s practice as the first contact into the health care system is likely to become increasingly challenging for practices seeking to be a medical home. Rapid-access clinics and emergency rooms are designed around convenience, which is a substantial driver in choice of care. SBHCs have been shown to be the preferred first site of contact relative to other community health centers and also led to decreased urgent and emergent care use.8 It is noteworthy that children from minority, low-income, or who are uninsured have the lowest chance of being in a medical home, yet these same children are more likely to use a school clinic than other community providers.20–22 Adolescents in particular have been shown to be more comfortable accessing a school clinic rather than other sources of health care, with higher degrees of perceived confidentiality, trust, and ease of communication cited as explanations.4,23–25

The AAP emphasizes that even if a child receives most of his or her care through a school clinic, they should be taught how to access care through their medical home and be formally linked to a permanent PCP. When this linkage is made a priority, the telehealth school clinic becomes a valuable tool enabling increased access to a personal provider for children with geographic, economic and situational barriers to care. It is important to note that in many communities, especially health professional shortage areas, there are often not enough physicians, let alone pediatricians, to see all of the patients needing care. Therefore, it is essential to recognize and support that nurse-run practices (led by masters or doctorally prepared advanced-practice registered nurses), comprehensive SBHCs, and comprehensive tSBHCs have the ability to serve as a patient’s PCMH.

Healthcare Provider-Directed Practice

The principle of health care provider-directed practice calls for a team approach to care that embodies enabling relationships, a sense of leadership, and healthy avenues for communication. Understanding adherence to this principle generally relies on measures of care management.19 This principle is synergistic with that of whole-person orientation and coordinated care as it is intended to provide the guidance to make the other principles possible. A tSBHC enhances a health care team’s ability to provide this guidance as it is a mechanism for a PCP to arrange multidisciplinary care that is centralized around the child. The school as a health care site has tremendous potential to bring all aspects of care to the child, and the connection to the PCP can allow this care to occur without redundancy and with coordinated purpose.

Speech therapy services at schools provided through telehealth technology is a widely implemented, well-researched, and successful example of this multidisciplinary care. This therapy is often utilized in the school setting, but there is often little involvement of the child’s physician when the management occurs. Speech therapy via telehealth in the school setting has been demonstrated to be effective and equal in efficacy to face-to-face therapy.26,27 In a community in which both primary care services and speech therapy are available through telehealth, the PCP has the potential to refer a patient for treatment through the school, facilitate care management discussions, and even participate in multidisciplinary visits without leaving the office.

Whole-Person Orientation

The PCMH principle of whole-person orientation calls for the provider to be responsible for all of the child’s health care needs, including arranging care with other health professionals. Thinking of the full scope of health services that this potentially entails can be somewhat overwhelming for a solo practitioner. Once again, the access provided by the setting of school health combined with the ability to bring in expertise remotely via telehealth allows the school telehealth approach to deliver on this principle. Few primary care clinics can boast the level of primary care, healthy lifestyle, mental health, and dental health services offered by many school clinics; not to mention the benefits of ease of access to students, their individualized education plans, and convenient lines of communication with teachers and other school services.3 Telehealth brings the possibilities of these services to resource-poor or remote schools, enhanced mental health capabilities such as parent-child interaction therapy, and subspecialist consultation with the true possibility of multidisciplinary visits. University of Kansas Medical Center’s TeleKidcare program is notable for providing such enhanced mental health and developmental care in the school setting.28

Coordinated and/or Integrated Care

The call for integrated care has brought to the forefront the need for tools to coordinate the complex elements of the health care system and center them around the patient.18 Although it can be readily demonstrated that school-based telehealth can address convenient and expanded access to health care, it is the linkage back to the PCP that allows a telehealth school clinic to enhance an existing medical home. To this end, tSBHCs should be integrated with other health care sources in the community. This is advocated for by the AAP and has been demonstrated to occur.1,29 It is helpful to recognize that the majority of SBHCs have an established health care entity as their sponsoring organization3 and therefore have the potential to assist this entity in fulfilling the requirements to be designated a PCMH. Additionally, telehealth opens up the potential for true integration in which the PCP is able to be the clinician in the school setting and simultaneously maintain a traditional office.

Quality and Safety in the Telehealth School Clinic

The conspicuous absence of a PCP in the telehealth school clinic’s physical plant may lead some to be concerned about how quality and safety are affected. Consistent with the summary of the Joint Principles of the PCMH (2007),18 quality and safety are achieved by utilizing evidence-based practices along with instituting plans for continuous quality improvement (CQI). Successfully implementing a CQI plan requires collaboration among members of the health care team, regardless of location, and includes participation and input from families and community representatives. Health care initiatives benefit in this area from interaction with operations of the school system, as the concept of collaboration is essential in school health. The collaborative school health model also requires cooperation among members of the school community, with the school nurse serving as the “coordinator of care, information, education, personnel and resources.”30 As an experienced facilitator, the school nurse has the potential to support quality improvement efforts. Many telehealth programs rely on the school nurse as the presenter for the clinical interaction. This enhanced role for the school nurse goes beyond facilitation, as this nurse can be a cornerstone in improvement efforts, bringing together the resources of the school and the health care team.

Enhanced Access

The University of Rochester’s Health-e-Access program is the most-studied school-based telehealth program in the United States and has demonstrated improved health outcomes and health care utilization. Evaluation of the Health-e-Access program found an overall increase in utilization for children who accessed the telehealth service of more than 20% but a decrease in emergency department use of the same magnitude.31 In this case, the desired outcome was achieved: more access to care in the correct setting. The program led to significant cost savings through the use of school-based telehealth. If the program prevented 0.5 emergency department visits per child who used the program annually, the cost of the program would be covered.31 Additionally, the Health-e-Access program demonstrated that 85% of acute visits to primary care pediatrics could be completed through telehealth,32 and that the frequency of disagreement on diagnosis between providers was the same for telehealth visits and in-person visits.33

Conclusion

Telehealth not only has the potential to make SBHCs more efficient and sustainable, but also synergistically enhances the ability of school-health initiatives to deliver the core elements of the PCMH model. Although fragmentation of care remains a concern as health care access points increase, the tSBHC is well-positioned to both improve access to and maintain the continuity of the PCMH. Being prepared to incorporate SBHCs and tSBHCs into a PCMH enables providers to improve the scope of care they provide to their patients and strengthen their local health care communities.

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TeleSchool-Based Health Center Models

tSBHC Program Location Services Offered Provider Model Service Model
Health-e-Access Urban (New York) Acute care Collaboration of academic institution- and community-based providers Visits are recorded and viewed later by the providers
TeleKidcare Urban (Kansas) Acute care, mental health, child development assessments Academic institution-based providers Real-time video conferencing sessions
MY Health-e-Schools Rural (North Carolina) Acute care, preventive care Community-based provider Real-time video conferencing sessions
MUSC School-Based Health Centers Urban/Rural (South Carolina) Acute care, preventive care, specialty care Collaboration of academic institution- and community-based providers Real-time video conferencing sessions and on-site care
Miami Dade School Telehealth Urban (Florida) Acute care, preventive care, specialty care Academic institution-based providers Real-time video conferencing sessions and on-site care
Authors

Stephen W. North, MD, MPH, is President, Center for Rural Health Innovation, and Assistant Professor, University of North Carolina School of Medicine. James McElligott, MD, MSCR, is Medical Director for Telehealth, Department of Pediatrics, Medical University of South Carolina. Gaye Douglas, DNP, is Assistant Professor, School of Nursing, Francis Marion University. Amanda Martin, BA, is Executive Director, Center for Rural Health Innovation.

Address correspondence to: Stephen W. North, MD, MPH, 120 Oak Street, Spruce Pine, NC 28777; email: steve.north@chri.org.

Disclosure: The authors have no relevant financial relationships to disclose.


10.3928/00904481-20140127-08

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