School-Based Telehealth Innovation
By Susan A. Orban, LICSW, Director, Washington County Coalition for Children, RI
“The current youth mental health crisis has been brewing for decades.”
The Current Youth Mental Health Crisis
The current youth mental health crisis among youth has been brewing for decades. In fact, Dr. Gregory Fritz, (former Brown University Psychiatry Professor, Bradley Hospital Medical Director, and Hasbro Children’s Hospital Director of Children & Family Psychiatry) wrote about the budding crisis in an Editorial published in The Providence Journal in 2005. Fritz’ article referenced the ‘boarding’ of children in psychiatric distress in hospital emergency rooms, as well as the “lack of access to outpatient child mental health services in the community because of a shortage of providers.” Little has changed since Fritz sounded that alarm so long ago.
In Washington County (located in southern Rhode Island), just as Fritz described, access to outpatient children’s mental health services is limited. In fact, the county is a federally designated mental health shortage area. Our local community mental health center simply does not have the capacity to serve our region’s children, two thirds of whom have private insurance.
As more and more children in crisis boarded in our two community hospitals, which do not provide any pediatric services, let alone psychiatric services, one of our local federally qualified community health centers (FQHC) stepped up to fill the void.
Increasing the Behavioral Health Provider Pipeline
To increase the number of psychiatric prescribers for children in Washington County, Thundermist Health Center developed a competitive 1-year post-graduate fellowship program for Pediatric Nurse Practitioners (PNP), that includes advanced training and supervision from the state’s leading psychiatric experts. After the fellowship, Thundermist then recruits top performing fellows to work for them. Thundermist built out their behavioral health practice in Washington County to include outpatient therapists with expertise in various pediatric conditions (ADHD, anxiety, depression, substance abuse, etc.) and special populations (developmental disabilities, LGBTQ+, etc.).
The program includes care coordination and triage to higher levels of care if needed. Because access to mental health care is so limited and most children in Washington County are cared for by pediatricians in private practices, Thundermist sought permission from their federal funder HRSA to provide outpatient behavioral health services for children & adolescents for whom they do not provide primary care. Typically, this is not allowed by FQHCs unless a compelling need can be documented. Thundermist offers psychiatric evaluations, medication evaluations, and outpatient counseling to children and adolescents referred by their non-Thundermist primary care providers. Through this novel program, Thundermist has not only expanded their psychiatric PNP provider workforce, but has served well over 400 Washington County children since the program launched in October 2019.
Leveraging Telehealth to Reach Students at School
While largely successful, this innovative solution still requires youth and their families to come to Thundermist for care. Too often logistical challenges, such as transportation, lack of insurance coverage or high co-pays, childcare conflicts, or limited afterschool/weekend availability for appointments, get in the way of students being able to obtain needed mental health services. That is until COVID-19 forced everyone to think and do things differently.
With global use of distance learning and telehealth, adults and children everywhere became comfortable using video conferencing and insurers began covering telehealth services more widely. In fall 2021, we were fortunate to learn about Heywood Healthcare’s School-Based Telehealth Program in rural Massachusetts. We believed adapting this model on top of Thundermist’s PNP Program would reduce logistical barriers and increase needed access to care in a setting where children already gather.
Thanks to a grant from the van Beuren Charitable Foundation, in fall 2022, the Washington County Coalition for Children partnered with Thundermist and Narragansett School System to pilot tele-behavioral health services for middle and high school students during the school day. The school system provides access to confidential spaces for students to participant in their telehealth sessions. A Community Health Worker (CHW), employed by Thundermist, but placed in the school district, helps facilitate student appointments with behavioral health providers and coordinates care between parents, students, school staff, and health and behavioral health providers - ‘connecting the dots’ and assuring integrated healthcare.
The CHW notifies classroom teachers about student appointments and sets up telehealth technology. After sessions, the CHW assures students are stable to return to class. Since Thundermist can bill all insurances and care for those uninsured, insurance barriers are eliminated. Knowledgeable in available community resources, the CHW can also support families with other needs they may have, linking them with needed resources for housing, food, health insurance, heating assistance, etc. Services by CHWs are Medicaid reimbursable, which provides a potential funding stream for sustainability of the program. In essence, this program serves as a virtual school-based health center, without the onerous regulatory and larger space requirements. During the first year of operation, 32 students received services through the program. The most common concerns identified included anxiety, depression, and substance use. Many students had not obtained mental health treatment prior to the telehealth program. Even more importantly, as a result of this effort, stronger working relationships have been forged between Thundermist, Narragansett School System, and the Coalition.
More Innovation Required
To address the current youth mental health crisis, there is no question we must work to increase access to quality mental health care. However, more creative solutions and innovation are required to address the needs of today’s youth, who too often are overwhelmed by the everyday pressures of their academic, family and social lives, engagement with social media, fears of school shootings, and exposure to threats in an ever changing and unsafe world. To ensure all our children can thrive, we must facilitate cross-sector collaboration and foster new partnerships to build a culture that truly supports healthy youth development and well-being.
Susan A. Orban, LICSW
Director, Washington County Coalition for Children
The Washington County Coalition for Children is a regional child advocacy organization whose priority is children’s mental well-being. The Coalition has been working collaboratively to foster innovation and improve child outcomes in Washington County for over 20 years.
