The more than 900 students at Apple Valley Middle School in Hendersonville, NC usually keep the campus buzzing with activity. But a week after the fall semester began, only a few cars dot the parking lot and the front-facing windows of the single-story building reveal empty classrooms. Inside, footsteps and soft voices echo through the near-vacant corridors.
It’s been this way since late March when Governor Roy Cooper ordered schools closed statewide. By the time the scheduled spring break rolled around two weeks later, the temporary closure had been extended through the end of the term. The new school year began in August with teachers and staff working remotely and students learning virtually.
Apple Valley is home to one of 13 Blue Ridge Health-operated school-based health centers (SBHCs) in the western part of the state. Through all the modifications and uncertainties, the SBHC staff has continued to deliver health care to the students who rely on them.
“We work to meet the needs of all of those kids,” said SBHC practice manager Mandy Slagle. “This is a safe place for whatever they need. Ideally, all schools should have a school-based health center. If they could access health and behavioral health services without having to worry about having insurance, so many more kids nationwide can be served.”
SBHCs are precisely what the name implies: a campus-based doctor’s office that provides a range of health care services for students, teachers and staff. For many rural, low-income residents in health care deserts, SBHCs are their only access to care. Some are funded through private grants but many others are supported by state and federal appropriations. Most partner with the school district and a community health organization, such as a community health center, hospital, or local health department. All are committed to serving every student, regardless of insurance or ability to pay.
With permission from a parent or guardian, students are enrolled at the beginning of the school year and can take advantage of available resources. In addition to seeking medical attention for acute issues like ear and stomach aches, enrollees can also receive chronic disease management, immunizations, well-child checkups, sports physicals, adolescent medicine consults and hearing and vision screenings.
North Carolina law allows minors to seek medical health services for the prevention, diagnosis and treatment of sexually transmitted diseases, pregnancy, substance misuse or emotional disturbances without parental consent. The emphasis on prevention, early intervention and risk reduction allows providers to counsel students on healthy habits and how to prevent injury, violence and other threats.
The American Public Health Association says SBHCs address bullying, violence, anger, depression and other social and emotional issues that can impede academic achievement. Locating these health services on campus improves access that can lead to better student health and academic outcomes, such as higher GPAs, attendance, grade promotion, college preparation, and reduced rates of suspensions.
The Health Care Solution for Rural Communities
According to the most recent census by the National Assembly on School-Based Health Care, there are nearly 2,000 SBHCs located in every region of the country. But the shortage of health professionals, distance to services and geography make these care facilities even more critical to rural communities where, according to an NPR poll, one out of four people say they can’t get the health care they need.
North Carolina has been working to solve the problem for decades with little success. In the western part of the state, the doctor-patient ratio can be as high as one to 2,000 in some of the most remote areas. SBHCs bring together educators and health practitioners to bridge the health care and education gap and help reduce the disparities that impact rural schools.
When Steve North was a Teach for America fellow in eastern North Carolina in the early 1990s, he saw how unaddressed medical problems kept his students from reaching their academic potential. “The kids were frequently coming to school sick or missing lots of school,” recalls North. “I started doing some reading and got turned on to the idea of school-based health centers, which were relatively new on the national scene at the time.”
What he learned persuaded North to return to school and earn a medical degree. While practicing family and adolescent care medicine in Bakersfield, a remote mountain town with fewer than 500 residents, he continued to look for ways to provide better care to the children he served. A Jim Bernstein Community Health Leadership fellowship allowed him to start the Center for Rural Health Innovation, a 501(c)(3) non-profit dedicated to improving rural access to health care, and launch Health-e-Schools to provide primary care and behavioral health services.
Health-e-Schools began in 2011 with just three schools but now serves more than 25,000 students in 80 schools across three western counties. Using high-definition video conferencing with specially equipped stethoscopes and cameras, a centrally located health care provider can examine students at multiple schools without traveling.
“Parents might work 30 miles in one direction and children go to school 20 miles in the other,” says North. “Before this, when that inevitable call comes in that says Johnny is sick, parents had to drive to school, pick up the child and go to the doctor’s office. A lot of those people would end up in the ER who probably didn’t need to be there.”
As these programs expand, equipping them becomes more economical, says North. “It used to cost $30,000 to put telemedicine technology in a school. We can now equip a school nurse for about $2,000, with a better piece of equipment that they can take from school to school.”
School Care in the Age of COVID-19
The Pender Alliance for Teen Health (PATH) operates three SBHCs on the opposite side of the state. Located on the southeastern coast on the Atlantic Ocean, the poor rural county has had more than its share of school and health challenges recently. In September 2018, Hurricane Florence dropped more than 40 inches of rain in one day, leaving 70 percent of the county under water, damaging some 3,000 homes and displacing tens of thousands of residents. Schools remained closed for 29 days while families tried to rebuild or relocate. By the time the coronavirus pandemic hit 18 months later, hundreds of families still lacked permanent housing.
“The pandemic is like a second wave gut punch for Pender County,” said Sandy Rowe, PATH executive director. “We were still reeling from Florence. With the poverty, remote areas and the domestic violence against our kids, they are feeling like they can’t count on anything. We’ve focused on doing what we can to reach them and offer services early enough in the process so that we don’t have a bigger problem later on.”
The pandemic brings unique challenges to rural communities already affected by high levels of poverty, lower levels of health care access and literacy. Even before this most recent run of bad luck, Pender County residents faced many obstacles to health care access. It is not unusual for families to drive 50 miles one-way to see a health care provider. PATH was deemed a success from the beginning, but the program is considered a necessity in helping the school system and community navigate life in the pandemic.
“We have certainly improved their access,” said Kimberly Collins, lead nurse for Pender County Schools. “More kids are getting their annual physicals and getting vaccinated on time. Our staff is able to see them for whatever needs they might have without having to leave work or take a whole day off, or even a half a day off.”
Unlike many school districts in the state, Pender County students participated in in-person summer school and began the fall semester with a combination of in-person and remote learning. PATH personnel used the opportunity to educate the community about the virus. They stressed safety measures and behaviors believed to reduce the spread, such as high vaccination rates, mask compliance and regular handwashing. On campus, they ensure that the guidelines are understood and followed. Everyone is screened before entering the building. Masks and social distancing are required at all times. Meals can be picked up from the cafeteria but must be eaten in the classrooms.
“We look at COVID first and foremost from a health and safety perspective,” said Collins. “As soon as we get information, we inform that family right away if they need to be isolated or quarantined so that we can keep everybody in our school system healthy and safe. We also have a particular focus on people getting immunizations and flu shots this year since both are communicable and the symptoms are very similar.”
A Greater Need for a Behavioral Care
COVID-related anxiety, isolation and displacement has resulted in collective trauma for parents and children and a greater need for behavioral health clinicians. But a study in JAMA Pediatrics found that 72 percent of North Carolina children diagnosed with a behavioral health condition waited more than a year to meet with a licensed mental health provider. According to the North Carolina Institute of Medicine, this is due in large part to the shortage of Specialized Instructional Support Personnel (SISP) such as nurses, counselors, psychologists and social workers. For example, the recommended ratio is one social worker for every 250 students. North Carolina has one for every 1,427 students.
Lack of high-speed internet can complicate telehealth delivery in rural communities, but SBHCs have made great strides in using technology to connect students to counselors, psychologists and social workers. After school closures at Apple Valley, counselors scheduled virtual sessions for every child who had been receiving behavioral health care during the school year.
“The technology piece was a little cumbersome at first, but I think some of the kids prefer to continue with their virtual sessions as time goes on because they enjoyed that interaction,” explains counselor Anna Mamo, LCSW. “We schedule telehealth appointments in the afternoon because the kids have virtual learning in the mornings. We try to choose the times when they have classes like band, chorus or PE so that they’re not missing their core classes.”
When a post-Hurricane Florence mental health risk assessment found that 30 percent of the children were at risk for depression, PATH added two full-time teletherapy counselors, and a health coach to its team of providers. It also boosted preventive measures by developing a mindfulness curriculum for teachers.
Health-e-Schools addresses students’ complex mental health needs through a partnership with Mission Health, western North Carolina’s largest health care system. Now, the kids can see a provider and return to class before the school day ends.
There is a growing recognition of the value school-based health centers have to their communities. In 2016, the Federal Office of Rural Health Policy and the Health Resources and Services Administration (HRSA) encouraged expanding access to SBHCs and provided more than $6 million in grants for rural telehealth programs. Last year, HRSA awarded $11 million to SBHCs for technological upgrades. This is a win-win that bodes well for the growth of SBHCs, particularly in rural areas.
Melba Newsome is a 2020 EWA Reporting Fellow. This story is produced as part of EWA’s drive to support enterprising journalism that informs the public about consequential issues in education.