During the pandemic, Children’s National Hospital in Washington, D.C., developed a school-based telehealth program to connect students with a Children’s National physician when needed while keeping them in school. Shireen Atabaki, M.D., M.P.H., medical director of telemedicine on the emergency medicine team at the hospital, recently spoke with Healthcare Innovation about the program’s impact on students’ physical and mental health and plans for future expansion.
Healthcare Innovation: How long has Children's National been working with the District’s schools on telehealth? Did it start during the pandemic?
Atabaki: We did start the program during the pandemic. Right before the pandemic, the District had put out a request for proposals for telemedicine in the schools, D.C. public and public charter schools. We responded to that request for proposal and received a four-year grant to establish telemedicine in all of the Districts public schools and a percentage of the District's public charter schools.
HCI: Was there already a need for this type of service before the emergency of the pandemic?
Atabaki: Yes, absolutely. The schools have school nurses, but having a physician or licensed independent practitioner available for more thorough medical care is important, especially in the most underserved wards in the District, where children don't necessarily have all the resources for comprehensive care and specialty care that they need. It also allows families to save time away from work. Many working families are really dependent on their salaries or hourly wages for income and they can't afford to lose a day of work. So it has been very helpful. And for children with chronic illness, and those requiring subspecialty care, it’s also been very helpful in connecting them to those services much more quickly.
HCI: Children’s National partnered with the telehealth vendor Amwell on this project. Had it previously worked with that company on other initiatives?
Atabaki: Yes. We also worked with them on the Connected Care pilot program funded by the FCC. We picked them from several vendors, just because of all the capabilities they had, including integration with our electronic medical record. That FCC grant was to provide connected care services for underserved children and families in the region through telehealth. It includes things like smartphones and unlimited data plans for underserved families. It allowed for some other services — some fetal maternal health as well as the Amwell platform for underserved patients and families.
For the school program, we have devices in every school. That includes a digital stethoscope and otoscope and something called a dermatoscope, so you can do a full exam — listen to the child's heart and lungs remotely and look in the ears to diagnose things like otitis media, look in the throat to diagnose a sore throat.
HCI: Does that require some additional training for the school nurses?
Atabaki: It does. We had a very robust training program. We were able to train 100% of the school nurses on the use of those devices before we rolled out the program. We had a first pilot year where we were doing a lot of phone consultation and had our providers in place. Then we began to build up the program starting with 12 schools in our first year in the most underserved wards of the District, then building up to the current of 178, which includes all D.C. public schools and several D.C. public charter schools.
HCI: You’ve mentioned grant funding. Is there a way for the program to be sustainable longer term and for Children’s National to get reimbursed through insurance or would it need extended grant funding for it to continue and expand?
Atabaki: At this stage, especially since we're looking at a focus on underserved children and families, we do need grant funding and some kind of collaboration. We're always looking for additional funds. We are extending into the tele-psychiatry and tele-behavioral health realm, which is a much-needed service. There is a huge need for it and a paucity of services. Unfortunately, it can take up to one to two years to get mental health services, especially for children.
HCI: Is the process for a mental healthcare visit much different than for a physical health visit?
Atabaki: Both require consent. And the mental health visit does require some additional screenings that are a little bit more intense and/or extensive. There are more issues around privacy and we have to make sure the child is in a secure space. There are certain conditions in the District and several other states where the mature adolescent can actually seek care and receive that confidentially — substance abuse and some mental health issues being among those.
HCI: In this model, is it is it always a Children's National clinician doing the telehealth visit or is it contracted out?
Atabaki: Our model is it is always a Children's National provider. Our strength is our specialty services and the expertise and national reputation of our providers. They're involved in a lot of large clinical trials. They set national standards and write textbooks, so you're really getting the best of the best subspecialty or specialty faculty. On weekdays during the school day, we can, tap into our own primary care providers, and a lot of them have experience and interests in child advocacy as well.
HCI: Are there any next steps or aspects of the initiative to fine-tune going forward?
Atabaki: Absolutely. Expanding the tele-psychiatry program as well as subspecialty care for diabetes and increased asthma care, as well as helping patients with seizure disorders and patients with complex chronic diseases. All of that was in our original proposal, and unfortunately, because of some funding issues, we were unable to provide all of those initially. We are looking for funding to expand our tele-behavioral health program. I think that's going to be very important for children and youth in the District and really change outcomes for young people. We've seen a tenfold increase in suicidal presentations to emergency departments for children in the United States over the last 15 years. That's very dramatic. We really want to look at ways to make inroads to prevent and reduce that. I think school tele-psychiatry and tele-behavioral health is an important place to start to recognize mental health issues and get interventions early on before things spiral out of control.
