In 2013, what was then known as Children’s Medical Center of Dallas plunked telemedicine capabilities in a pair of Dallas pre-schools. They wanted to see if there was a way to boost access to care when kids got sick, so they took it right to them. The school nurse would get consent from a parent, then schedule a telehealth consult with a Children’s physician or nurse practitioner when they had a free moment.
It helped with cases of light acuity—sore throats, earaches, that sort of thing—and organizers began researching plans to scale it. Now, two full years later (and a rebrand to Children’s Health System of Texas) the region’s largest pediatric provider has a school-telemedicine program that can be found in 57 campuses in urban (Lancaster ISD, Dallas ISD) and rural (Tom Bean ISD, Denison ISD) school districts throughout North Texas.
“The most important thing we’re looking at for the telemedicine-based program is, how can we improve the seat time—the time learning in the classroom—and not being out for doctor’s appointments?” asks Julie Hall-Barrow, the senior director of innovation and telemedicine at Children’s Health. “Mostly, we hear that the kid didn’t feel well last night, but they’re going to go on to school because they aren’t running a temperature. What happens if they get sicker during the day?”
That initial pilot program was tiny and the equipment was mobile, meaning the physicians could pack it up and move it place to place. Too, pre-schoolers proved to be a difficult crowd for telemedicine; they struggled to explain symptoms, often confused by the person asking them things on a screen. Hall-Barrow was hired on at Children’s around the time this launched and went to work assessing where it could improve.
There was a chance to get federal and state money to pay for expanding it. Children’s harnessed the 1115 Medicaid waiver’s DSRIP (Deep breath for this acronym: Delivery System Reform Improvement Programs, meant to improve access to care) funds to offset the costs. The next year, Children’s expanded to 27 campuses. And on Wednesday, the Dallas-based system announced it would be expanding to 57, launching at new schools in Dallas, Grayson, Collin, and Tarrant counties. By 2016, Children’s hopes to be in 80 campuses.
To judge where to place a program, analysts researched data for emergency room usage that showed where children were seeking help for low acuity illnesses. That could be a sign that a parent got off work late and couldn’t get the child to a doctor before the next day of classes, Hall-Barrow said. Other cases were more obvious; the city of Lancaster, for instance, has no pediatrician, she says. If the child doesn’t have insurance or primary care provider, the physician can refer them to a Children’s case manager to help education about CHIP or find a physician close to them.
“I’m so thankful now that as the program has grown that we do have access to our behavioral health and case managers,” says Dr. Stormee Williams, the medical director for school-based telemedicine. “There definitely will be times, and have been times, that are outside of the scope of telemedicine that need to be followed up on.”
The 1115 Waiver has helped pay for telemedicine units for the school nurses, which cost about $22,000 each. These include computer equipment; ear, nose, and throat scopes; stethoscopes; derma scopes; and, this year, rapid testing strips for flu and strep throat. But that waiver expires next September, and it hasn’t yet been sent to the feds for renewal. During the last legislative session, Children’s worked with state Rep. Jodie Laubenberg, R-Parker, and state Sen. Van Taylor, R-Plano, to get House Bill 1878 passed. That will allow Children’s to be reimbursed for primary care services offered via telemedicine even if the doctor isn’t the patient’s primary care physician.
The Children’s project also skirts the recent telemedicine rule passed by the Texas Medical Board, which mandates a patient meet his or her physician before receiving care over the phone or by streaming video. Schools are exempted as appropriate care sites.
Going forward, the health system will likely choose to enter into more preventive and educational services—if a student is having issues with their weight, guide them to nutritional information. If a student is showing signs of undiagnosed asthma, help the parent change things in the home to mute the occurrence.
“This is the second year that we’ve gone into the bigger school districts,” Williams says. “I’m looking forward to the school nurses using our services more and them getting more comfortable with it.”