Cristi Wilson has relied on a school-based health center in Montrose, Colorado, through years of sinus and ear infections, sore throats and routine check-ups for her two kids.
When one daughter broke her arm, the health clinic was able to take an X-ray more quickly and inexpensively than the emergency room would. Wilson said the clinic saved her family hundreds of dollars on that visit alone.
Now that the clinic is closed for in-person visits because of the coronavirus pandemic, Wilson’s daughters are still able to get care by consulting with clinicians via video calls.
In some areas of Colorado, school-based health centers (SBHCs) have been students’ only source of healthcare for miles. And they still are, with many of the centers having transitioned to providing telehealth services since schools were closed March 18. But appointments via video calls can’t address all patients’ needs and, for some families, can be logistically harder than visiting clinics in person. Those limitations combined with fear from the pandemic, families being unaware clinics are open and economic fallout on an already financially precarious population has contributed to some centers’ patient load dropping by as much as 75%.
“We know that going without healthcare for three months is a big deal for some children,” said Aubrey Hill, executive director of the Colorado Association for School-Based Health Care.
Lower numbers and a new reliance on telehealth
School-based health centers first started popping up in Colorado in 1978, when the Robert Wood Johnson Foundation began funding them across the country with the goal of increasing healthcare access for low-income children. Now, most of Colorado’s 63 centers are located along the Interstate 25 corridor and on the Western Slope. Collectively, Hill says, they served about 35,000 mostly K-12-age students and their younger siblings in 2019. Most are independent organizations that receive some state and federal funding.
Montrose’s Northside clinic is located inside Montrose’s Northside Elementary School and is owned by the Montrose County School District. Gov. Jared Polis’s March 18 order shuttering all school buildings forced it and most school-based health centers to stop providing in-person medical care and move into the virtual sphere. Polis extended the order on April 1, pushing school closures through the end of April, and then on April 22 said schools would be closed for the remainder of the school year.
Jennifer Suchon, a nurse practitioner who runs the Northside clinic, says it took her and the clinic’s two other staffers one day to switch to offering only telehealth services. The administrative transition took longer, as her team struggled to figure out how, under the state’s new relaxed telehealth regulations for medical providers, to bill for virtual visits at a comparable rate to in-person visits.
The Northside clinic typically handles 2,000 patient visits a year, but through telehealth, Suchon said, she is seeing 50-70% fewer patients. Northside’s mental health therapist is seeing even fewer patients — 80% less than normal. Part of the problem is that families aren’t aware the clinic is open via web conference. And part, Suchon added, is that many patients are making telehealth appointments but not calling in.
There are other challenges to providing health care over a video phone. For some types of telehealth visits, Suchon said, it “seems like they’re incomplete.” It is impossible, for example, to hear a patient’s heart beat or lung function without being able to check them in person. She noted that no patient has needed an in-person visit yet, though one may need hands-on care down the line.
Some centers are located on school grounds outside of the main buildings. Four of those in Aurora, managed by Every Child Pediatrics, remain open. Even so, Program Manager Ashley Coram says those clinics have been “very quiet,” which she thinks may be due to families’ fears about leaving their homes, especially for a medical setting during the pandemic. The four clinics treat 3,100 patients a year, each seeing about 13 to 15 patients a day before the pandemic. Now, the patient load is down to about two patients in-clinic and two by telehealth a day.
“There’s still a lot of fear around specifically coming into the clinic,” Coram said. “Even if they (families) know they (their kids) need to be seen, they know they need those vaccines, they’re still saying ‘let’s wait until late May, or even June.’”
Some types of appointments can be put off for a few months, Coram said, but there is concern that families won’t seek care until a child’s condition is urgent. The importance of primary care at the clinics, and in general, is ensuring consistent check-ups to avoid illness reaching the point of emergency, she said.
Also, because the clinics allow younger siblings of students to receive care, Coram recommends every child under 6 come in for wellness checks, even during the pandemic, because they still need critical vaccines. She and her team have been working to send word to families through Facebook, email or phone call that the Aurora centers are open, she said.
Unlike the medical providers, the Aurora clinics’ behavioral health providers have remained busy. Behavioral health visits can be more easily accommodated through video technology and counselors already had more consistent, ongoing schedules seeing behavioral health patients than medical ones, Coram said.
She added that behavioral health visits via telehealth can also be less daunting for some students, who may open up more readily through a screen than in an office.
“It’s been very welcomed to kind of have that connection and not have to come to a clinical setting and sit down and talk to someone you’re maybe not that well known to,” Coram said.
Systemic obstacles in caring for patients during the pandemic
The Summit Community Care Clinic sees about 3,000 students a year at its primary center in Frisco, four other centers throughout Summit County and locations in Fairplay and Leadville. All but the Frisco center are located inside schools and have been closed during the pandemic. Since the outbreak hit, the caseload has dropped by about 75%.
Christine Curtis, chief behavioral health officer at the Summit Clinic, attributes that drop partly to families choosing to stay home to avoid exposure to the new coronavirus and partly to the fact that many locals – especially immigrants – have packed up and left the area since ski areas and hospitality-related businesses have shuttered.
“We have a lot of families who have just left the county because there’s no ability for them to remain there,” she said.
She noted that some low-income families have difficulty taking advantage of telehealth because they don’t have internet or cell phone services. Disparities between who does and doesn’t own tablets and laptops are creating economic inequities in who can access health care.
The Northside clinic in Montrose’s serves a population that’s largely low-income. Most of its patients have Medicaid or Child Health Plan Plus, a public low-cost insurance program for children. About 40% of Northside’s patients are uninsured. For families without access to video technology, Suchon said the clinic is conducting visits by phone-call, sometimes relying on families to send over photographs of a child’s rash or sore throat in hopes those visual aids are helpful. The Montrose County School District, in the meantime, is working to provide children in 4th grade and higher with tablets for classroom work, which can help with telehealth visits.
In the more urban Aurora, access to technology has not been as big of a challenge because the school district there has provided students with tablets and Wi-Fi hotspots for online learning.
Still, language has posed a barrier to the extent to which the Aurora clinics are able to spread word that they’re open. Aurora, one of Colorado’s most diverse cities, is home to refugee populations that speak Burundi, Karen, Swahili and other languages the clinics’ staffers generally don’t speak, Coram said. The language barrier poses a challenge in letting families know the clinics are open when their contact information isn’t currently in the clinics’ system, she said.
Bright spots during a hard time
Despite the limitations of school-based health clinics, those who staff them say some support is better than no support – especially at a time when so many emergency rooms in Colorado have been focused on COVID patients.
“There’s a lot of selflessness from our staff,” said Curtis, whose clinic in Summit County tests about six or seven adult community members a day for the coronavirus, half of whom are positive.
“The community really depends on that clinic and you can certainly see that in times like this,” she added.
Correction: The previous version of this story incorrectly reported that the Summit Community Care Clinic tests six or seven children a day for the coronavirus.