How a health screenings pilot helped students at a California school get greater access to care

In the United States, many children lack access to primary health care. Factors like distance, economic hardship, sociocultural norms, language, and lack of health literacy can all become barriers to families accessing the health care they need and deserve. Children facing barriers to care are more likely than others to not receive treatment or to be undertreated for primary care issues.

For all people, having access to primary care is associated with positive health outcomes. Primary care includes preventative care, early detection and treatment of disease and injury, and care for chronic and acute illness. When a child has access to primary care, their growth and development is consistently monitored, which enables their provider to identify notable patterns or shifts and catch early signs of problems that should be addressed. To have the best chance at a healthy future, it is essential that children receive consistent, culturally competent care from a medical provider.

One way to increase access to care is through broadening the use and adoption of telehealth services. For those with limited access to in-person primary care, telehealth offers on-demand access to medical providers. Telehealth can help connect patients with the care they need by eliminating several key barriers to accessing care.

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How School Based Health Care Improves Access to Care for Children

Working in partnership with school initiators (nurses and trained staff), companies like Hazel Health provide children access to quality healthcare services in the school setting. Implemented as a stand-alone solution, or as a complimentary service to support existing school-based services, Hazel works with nurses, students services, counselors, and other school stakeholders to provide a seamless and unique healthcare experience.

Hazel medical providers (physicians, nurse practitioners, physician associates, and therapists) offer physical and mental health care, for a range of conditions including (but not limited to) headache, stomach ache, pinkeye, styes, menstrual cramps, minor injuries, sore throat, nosebleeds, nausea, fever, anxiety, depression, family issues, trauma, grief/loss, loneliness, and bullying.

How Hazel Works:

1. To launch the program, Hazel provides the necessary technology, equipment, and supplies (tablet, cart, over the counter meds, etc.) and works with school stakeholders to obtain parent/guardian consent so students can access the service.
2. Student visits the school nurse's office with a physical or mental health complaint.
3. For a physical health visit, with approved consent from the parent or guardian, the initiator, often the school nurse, initiates a Hazel visit through the Hazel platform. The student is connected directly, within minutes, to a Hazel provider.
4. The Hazel provider conducts a visit with the student. The provider assesses the student’s symptoms.
5. Post visit, the Hazel provider sends a visit summary to the primary care physician (if the family has one) and the parent/guardian (if the student is under 18). When needed, Hazel coordinates additional care, which may include referrals to the school counselor, behavioral health, dental, vision, etc.

Hazel, an advocate for the student, seeks to ensure that the student receives the care they need when they need it. After a visit, the Hazel provider sends detailed visit notes to the parent/guardian, and works to ensure the student is connected to any community resources they may require.

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Hazel Physical Health Screens Telehealth Pilot Program

To determine the value of using telehealth to fill medical gaps when students lack access to primary care, we conducted a 12-week long pilot study alongside a California school partner.

The goal of the pilot was to provide health screens to K-12 students that had not been seen by a physician in more than two years, and to explore the value of systematic screening to find and fill gaps in students' healthcare.

The objectives of the pilot program were to:

1. Introduce the Hazel program in the school
2. Understand students’ medical histories and identify any gaps in care that could be filled by Hazel or the school  
3. Administer high level screenings, including partial HEADSS assessment (part of a routine adolescent well visit), basic mental health screening (PHQ2/PHQ9 questionnaires), and SDoH needs screening
4. Provide an opportunity for education, counseling, and/or medical advice for any health related questions the student may have  
5. Confirm that the student has a good support system in place (home, school, peers, etc.) and assist with any gaps
6. Discuss COVID-19 vaccine/COVID-19 related questions or concerns

Determining the Student Population and Gathering Consent

In this case, the school’s counselor in the pilot school had identified that students who had not seen a PCP in at least 2 years tended to use urgent care for acute needs, for example, asthma exacerbations or lapsed prescriptions. These students were identified and prioritized for the pilot.

To provide care, Hazel required parent/guardian consent, unless the student was 18 or older and could self-consent. Verifications of consents were checked by Hazel staff and documented in the student’s chart within the Hazel application.

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Building the Health Screen Visit Schedule

In partnership with the school counselor, Hazel identified one day a week to conduct the health screen visits over the 12-week pilot period. One day a week, during school hours, Hazel providers conducted 30 minute health screen visits with the students whose parents or guardians had consented to the service.

Hazel physicians, nurse practitioners, and physician assistants conducted the health screenings through the Hazel telehealth platform. The providers rotated through the schedule to ensure both that time with the student was maximized and that e the provider had time to chart, order referrals if needed, and make any necessary calls to school staff and/or family after the screening.

The health screening visits began with an introduction to Hazel Health services and then the rest of the visit focused on the student’s health-related questions, their health history, healthy habits, and any gaps in care or urgent health needs. Specifically, the medical screening protocol addressed:

• Acute and chronic health conditions
• HEADSS assessment
• Mental Health Screening (PHQ2/PHQ9)
• Social Determinants of Health Screening
• Asthma screens  
• Gaps in support systems (home, school, peers, etc.)
• Anticipatory guidance on nutrition, exercise, sleep, stress management
• Anticipatory guidance on COVID-19 vaccine/ COVID-19 related questions and concerns
• Anticipatory guidance on navigating the healthcare system

During the visit, the provider identified any concerns, determined urgency, and made recommendations to the student, family, and counselor, as needed. Referrals were made directly through the school counselor who connected each student to the appropriate resource, including health insurance navigators and mental health counselors at the school. Guardians were aware of this process before, during, and after (when necessary) to build trust, establish health literacy, and guarantee proper follow up. If a student had a primary care provider (PCP) on file, a faxed summary of the visit was sent to them.

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Key Findings from the Pilot Program

To determine impact, Hazel evaluated a range of metrics, including:

• Clinical: HEADSS assessment scores, PHQ-2/PHQ-9 results, number of counseling referrals made, SDoH needs identified, potential for impacting HEDIS metrics, Provider satisfaction scores
• Clinical Operations: Visit duration, charting duration, number of referrals, and number of escalations
• Engagement: Number of visits for health screens versus urgent care visits were noted per day
• Enrollment: Percentage of students consented  
• Program Evaluation: Anecdotal success stories and wins from students, their families, and/or school initiator

The pilot program found that working with school champions can make all the difference in bringing a new technology into a school. By having an internal champion within the school who advocated for and educated families about the program (the school counselor in this case), credibility and excitement for the program grew substantially. With a champion initiator advocating for Hazel, twice as many students were enrolled for the acute care service after the pilot (a 100% increase in enrollment).

Tapping into existing school resources, like navigators and support systems, positively influenced implementation. In terms of student impact, the pilot found that as the convenience and availability of care increased, students were followed more closely, and awareness of Hazel services increased. Students appreciated that if they needed care during school hours, they could use Hazel. After the screenings, students were able to better identify their mental health symptoms, and were more inclined to seek help and talk about their concerns. Additionally, LGBTQ+ students felt they received more specialist care and support.

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What’s Next for School Based Telehealth

The findings from the pilot support the power of telehealth in increasing access to quality care in the school setting. The pilot found that school based telehealth services impact not only the student, but also the family, school, staff, and community as well.

These findings are promising and compelling, and support that school is an appropriate and convenient place for a student to receive the healthcare services they need, or to at least get started on a path towards better health. Hazel addresses the many barriers to care that students experience, by bringing care directly to them, where they already are — in school.