In rural counties where healthcare access is sparse, simply taking care of a child with a cold can have far-reaching implications for parents. Innovative school-based telemedicine programs are beginning to meet that need, reducing absenteeism while creating a much-needed node for care in low-resource communities.
There’s an understanding in Mitchell County, North Carolina: if you miss your shift at the factory for any reason, don’t bother showing up tomorrow. “You don’t get to miss work and still have a job,” one Mitchell County resident told me. “You can’t leave and go to a doctor’s appointment. You can’t call in sick. It’s harsh.”
The zero tolerance policies common to the factories are made possible by what feels like compounding misfortune. Deep down, Mitchell County is an Appalachian mining community where the ground produces quartz and feldspar in unusual abundance and purity. The small mines that used to dot the mountainside were owned and worked by locals. Now, the conglomerate Unimin is the largest mining operation and third-generation miners hope for work. An assortment of manufacturing plants, the area’s second-largest industry, was, until recently, a buoy for the local economy. But in a recent six-year period, one town of two thousand lost a total of two thousand jobs when their work was outsourced to cheap labor. With unemployment still surging to fifteen percent, the community has yet to recover.
The offence feels more personal, though. For a working parent, something as common as a first-grader’s sore throat and the resulting call from the school nurse can mean choosing between a paycheck and medical care for a sick child.
“You have to weigh that carefully,” Amanda Martin said. “Can I leave to go get my kid? You put your job at risk every time you do that.” Martin is the executive director of the Center for Rural Health Innovation in Mitchell County. The center, a nonprofit with a mission to “apply innovative technologies to improve access to healthcare in rural communities” came out of Dr. Steve North’s work providing care in a school-based health center at the north end of Mitchell County. In addition to the isolation and the poverty, the shrinking job market and the stifling work schedules, North noticed that parents weren’t able to get their kids in to see primary care physicians. The schools, North said, were looking at unusually high absentee rates due to health problems that, otherwise, wouldn’t warrant missed class time.
The connection, he said, was obvious, and he soon began assessing other health data in the area. In a state where eight in ten counties are rural, Mitchell ranked 89th out of 100 in clinical care access. With only 15.6 physicians per 10,000 residents, it had been designated a Health Provider Shortage Area by the Health Resources and Services Administration. School officials said sixty-five percent of students utilized the free and reduced lunch program, which meant it was likely as many families depended on Medicaid. Finally, what was perhaps most telling, North said: in the previous year, seventy-five percent of daytime emergency department visits for children ages five to eighteen had been for non-emergent issues.
This was a community that had been subjected to the failings of a porous, incomplete healthcare system. North was determined to find an answer. A year later, he founded the Center for Rural Health Innovation and launched the Health-e-Schools program, which equipped three schools with a crude telemedical cart – general exam camera, digital stethoscope and otoscope, and a high-definition camera for imaging bruises, rashes, and the like – taught existing school nurses to operate the equipment, and gave them remote access to a physician and on-call nurse practitioner. Five years later, Health-e-Schools carts now feature fully integrated state-of-the-art diagnostic equipment and access to a cloud-based server that allows parents with access to a camera – a smartphone, perhaps – to conference in to their child’s visit.
For many families in the area, the Health-e-Schools program was the first regular access their children would have to a healthcare provider, and their only opportunity to escape a cycle of healthcare avoidance and preventable emergency room visits. “We’re able to evaluate and treat their child, send them home with follow-up instructions, and a prescription has been called in to a pharmacy that is open late,” Martin said. “That means that kid got care they were not going to get. And it may mean that parent keeps their job. That’s a game changer for that family.”
“Sick kids are the number one reason parents in America miss work,” North added. Last year, the Health-e-Schools program expanded to the neighboring McDowell County. Of the first one hundred visits they conducted at McDowell schools, only four students had to be sent home. “Previously, at least half of those kids, their parents would have needed to come pick them up and take them to the doctor,” North said.
Laura Brey holds encyclopedic knowledge on the many ways the access to care provided by school-based health centers can change a school and a community. She’s the Vice President for Strategy and Knowledge Management at the School-Based Health Alliance, and has worked in school-based healthcare for twenty-five years.
When school-based health is introduced, she says, “the whole environment of the school starts to change.” Students learn they can go to the school’s health clinic when they have an STD, maybe, or if there was no food at home for breakfast, and they’ll find an adult they trust. “It becomes a place where kids feel safe,” she said. The school-based health center then becomes a valuable tool for identifying issues like anxiety, depression, domestic abuse, and many other issues young people often face alone.
“One of the things we’re able to determine pretty easily,” North said. “Is this the stomachache that comes every Tuesday, first thing in the morning before a spelling test, or is it a bigger issue that needs to be addressed? What is the child really seeking?”
A communal approach, North stressed, is integral to their success. “We’re not just offering urgent care in the schools,” he said. “This needs to be part of the fabric of the health community.” Instead of replacing would-be primary care visits, the Health-e-Schools program aims to connect students with other community healthcare providers and, when necessary, partner with these providers to better manage chronic conditions.
It’s in this way that these programs can lift an entire community, Brey said. When kids are mentally and physically healthy, and when other social needs no longer go unnoticed, performance in school increases, school environments improve, families migrate back to public schools, an educated workforce rises up, and the value of reinvesting in your community becomes evident.
This seemed to be the way of things for Mitchell County. More than once I listened as someone unpacked for me how a single occurrence was invariably connected to everything else in the community.
One story came from Amanda Martin. She had been visiting her grandmother in the hospital when a nurse stopped her in the hallway. “You run that computer doctor program for the schools?” the nurse asked. Martin braced herself for a skeptical healthcare professional’s diatribe on the ineffectiveness of telemedicine.
“Once, I was working here at the hospital when I got a call from the elementary school that my son was sick,” the woman said. The school nurse had connected this woman’s son to a physician via a Health-e-Schools telemedical cart, they told her. Her son’s problem had been resolved and he had already returned to class. They were just letting her know.
“That meant everything to me,” she said. “I didn’t have to leave work. And the hospital didn’t have to find someone to cover my shift. They didn’t have to pay someone overtime. Someone else didn’t have to come in unexpectedly. I didn’t have to find someone to pick up my other son. We didn’t have to sit in the pediatrician’s office with my sick kid, and my new baby wasn’t in there licking all the chairs and tables. He would have been sick another week…”
“It had this ripple effect for her,” Martin said. And in one working-mother’s account of a single telemedical visit, it became evident just how deep into Mitchell County these doctors with cameras could reach.