The Journal of School Nursing2024, Vol. 40(3) 248–256© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211069911journals.sagepub.com/home/jsn
Utilization of telehealth in school-based health centers (SBHCs) is increasing rapidly during the COVID-19 pandemic. This study used a quasi-experimental design to evaluate the effect on school absences and cost-benefit of telehealth-exclusive SBHCs at 6 elementary schools from 2015–2017. The effect of telehealth on absences was estimated compared to students without telehealth using negative binomial regression controlling for absences and health suite visits in 2014 and sociodemo-graphic characteristics. The sample included 7,164 observations from 4,203 students. Telehealth was associated with a 7.7% (p = 0.025; 95% CI: 1.0%, 14%) reduction in absences (0.60 days/year). The program cost $189,000/yr and an estimated total benefit of $384,995 (95% CI: $60,416; $687,479) and an annual net benefit of $195,873 (95% CI: −$128,706; $498,357). While this cost-benefit analysis is limited by a lack of data on total healthcare utilization, the use of telehealth-exclusive SBHCs can improve student health and attendance while delivering cost savings to society.
Keywordstelehealth, school, cost-benefit
Reducing absences from school during kindergarten and elementary school is an important strategy for promoting longterm academic success and child wellbeing. While there are other barriers to attendance, illness causes a substantial proportion of absences in children (Wang et al., 2005). In addition to causing school absences, children’s illness can cause parents to miss work, both to care for the child and due to parental illness transmitted from the child (Neuzil et al., 2002). Increasing children’s access to healthcare can reduce the frequency, severity, and duration of childhood illnesses (Guo et al., 2005).
Schools have employed a range of healthcare service strategies to increase student access to care, including employing school nurses and forming school-based health centers (SBHCs) to provide primary care (Knopf et al., 2016; Leroy et al., 2017). A 2016–2017 national census of SBHCs identified four distinct primary care delivery models within the centers: traditional co-located centers with a nurse practitioner or other primary care provider; school-linked centers with offsite care at a fixed location; mobile centers with or without telehealth; and telehealthexclusive centers with on-site access to remote providers (Love, Schlitt et al., 2019). Telehealth is the exchange of medical information from one site to another using telecommunication technology to improve a patient’s clinical health status. Providing telehealth services as an alternative to traditional SBHCs in elementary schools is a strategy that can increase access to health care, improve children’s health, and potentially reduce absences from school (Reynolds & Maughan, 2015). While traditional SBHCs were started in the 1960’s and 1970’s, telehealth-exclusive SBHCs began only in the last decade, accounting for 0.2% of centers in 2013–2014 and increasing rapidly to 10% in 2016–2017, with the majority of these SBHCs located in two states (TX and GA) (Love, Schlitt et al., 2019). Over half of the telehealth-exclusive SBHCs in the 2016–2017 census were located in rural areas, implemented in part to manage provider shortages and long travel times. Additionally, 51% of telehealth-exclusive SBHCs were located in elementary schools (Love, Panchal et al., 2019). The COVID-19 pandemic has led to rapid deployment of telehealth services provided through SBHCs, many of which were forced to close their physical locations when their host schools closed (Sullivan et al., 2021). The proportion of SBHCs using any telehealth services increased by more than 200% before and after school closures in the spring of 2020; 40% of visits among SBHCs remaining physically open were conducted via telehealth (Sullivan et al., 2021).
Although there was growing interest in implementing new telehealth programs prior to the COVID-19 pandemic and a dramatic increase during the pandemic, evaluation of their impact and cost-benefit has been limited (Reynolds & Maughan, 2015). A recent systematic review of school and childcare telehealth evaluations from 2006 to 2018 identified no studies that evaluated the cost-effectiveness or costbenefit of telehealth programs (Sanchez et al., 2019). Only one report was identified that presented the cost of implementing school telehealth services (Forducey, 2006). A number of studies evaluated telehealth services for speech and language impairment, type 1 diabetes, and other special healthcare needs, but few studies have evaluated school telehealth services provided to the general student population (Sanchez et al., 2019). Of the evaluated telehealth programs that targeted general student health and reported overall health effects or healthcare utilization, all three were implemented in early childhood or elementary education settings (McConnochie et al., 2007, 2009; Ronis et al., 2017).
The 2016–2017 SBHC census report called for additional research on the staffing, utilization, health outcomes and user experience of telehealth in SBHCs (Love, Schlitt et al., 2019). The operational characteristics of telehealth-exclusive SBHCs in elementary schools are of particular interest given the often-smaller student population at each school site compared to middle and high schools. The use of telehealthexclusive SBHCs within elementary schools has the potential to leverage the clinical and setting-specific expertize of existing school nurses while expanding primary and specialty care (e.g., psychiatry) at scale potentially at a lower cost than providing specialty telehealth care within a traditional SBHC model. Although elementary school students accounted for 40% of the student population served by SBHCs in 2016–2017, SBHCs only reached 13% of all students, leaving substantial room for expansion if sustainable financial models are available.
As part of a quality improvement process initiated by a county in the mid-Atlantic region, the purpose of this study was to evaluate the effectiveness of telehealth at reducing absences and cost-benefit of an elementary school-based telehealth service compared to standard school-based wellness services in similar schools in the same school district. This study did not have access to data on overall health effects or healthcare utilization and is focused on the societal costbenefit of telehealth to reduce school absences.
The study utilized a quasi-experimental design to evaluate the within-child change in absences following enrollment in an elementary school-based telehealth program compared to students in similar schools in the same district without a telehealth program. The study used statistical controls at the individual level to account for selection at the school and individual levels. The use of telehealth visits and absences in the period prior to telehealth enrollment is the primary method for controlling for individual-level selection bias. As an alternative to randomized controlled trials (RCT), this quasi-experimental design with pre-post outcome measures and individual covariate control provides both strong external and internal validity well-suited to address limitations of many RCTs in the context of economic evaluation (Cook et al., 2002; Drummond et al., 2015).
The study was determined to be a quality improvement project and not human subjects research by the George Washington University Office of Human Research.
In December 2014, the county launched the first schoolbased telehealth program in its state. The program is run by the county health department in close partnership with the county school district. The program began in SBHCs in five schools serving pre-Kindergarten to fifth grade and expanded to an additional school the following year. Five out of the six schools that implemented the telehealth program were eligible to receive Title I federal funding provided to schools enrolling at least 40 percent of children from low-income families.
Enrollment and participation in the telehealth program was voluntary, however, a parent or legal guardian must enroll their child in the program prior to the first visit. Telehealth enrollment forms were sent home to all students in either English, Spanish or Haka Chin and are included in school enrollment and registration packets. When students enrolled in the telehealth program visited the health suite with a health complaint, the school nurse triaged the student to determine whether telehealth services would be appropriate. If the nurse determined that telehealth services would be appropriate, they first contacted parents or guardians. School district policy requires that the school nurse contact the child’s parent or guardian to provide phone consent for each telehealth visit. If consent was given, the school nurse established a secure video link with a medical provider at the county hospital or the student’s pediatrician if they were participating in the program. At the time of the telehealth visit, the parent had the option to participate and observe the telehealth visit on their computer or smartphone app utilizing a secure, real-time video link. Once the visit with the medical provider was initiated, the school nurse used a digital camera, stethoscope, and otoscope with direction from the medical provider conducting the examination virtually. After the telehealth visit, the medical provider could send any prescription medications directly to the child’s pharmacy. No blinding of participants or providers was implemented.
The county school district provided de-identified student records including attendance records and demographics from fall 2014 to spring 2017. In order to estimate the effect of telehealth on illness-related absences, the following attendance categories were excluded from the analysis: tardy unexcused, tardy excused, weather hazard, suspended-out, religion, out-of-school suspension, no transport, immunization, family death, court, and absent unlawful. Absences include the following attendance categories: absent, absent excused, appointment, health related exclusion, illness, and local discretion. Observations from students with less than a complete year of enrollment were dropped from the analysis as school transfer may be related to illness or other unknown student and family characteristics related to enrollment in telehealth or absence from school. Telehealth utilization and diagnosis data were obtained from the county health department. Data from each telehealth visit, including demographic information, diagnoses, prescriptions, repeat telehealth visits and return-to-class information are maintained by the health department telehealth program administrator.
The difference in absences was estimated among students enrolled in the telehealth program in the 2015–2016 and 2016–2017 school years compared to students not participating in the program in all Title 1 schools in the district. Enrolled students were chosen as the intervention group instead of students utilizing the telehealth services because utilization would be associated with illness and there would not be an appropriate method for selecting control students with similar levels of illness. To address overdispersion, the effect of telehealth on days of absence per year was estimated using a negative binomial regression model. Generalized estimating equation methods were used to account for clustering (Cameron & Trivedi, 2009). The following variables were included as controls: gender, race/ethnicity, grade level, language spoken at home, free and reduced-price lunch eligibility, school, absences (Fall 2014), and health suite visits (Fall 2014).
The cost-benefit of the program was estimated using a societal perspective with the goal of informing stakeholders and decision-makers at the county level.(Neumann et al., 2016) The time horizon for the evaluation was a single school year with no discounting applied. Cost data were collected using microcosting procedures (Drummond et al., 2015). Data on equipment and salary were provided by the county health department and school district. All costs are reported in 2017 dollars. Capital equipment was amortized assuming a 3% discount rate and 5 years of useful life. Overhead costs were not included. Program operating costs were estimated using existing program budgets and consultation with school district and health department staff to determine opportunity costs.
School nurse time for telehealth visits was costed incrementally compared to a standard health suite visit. The cost of the nurse time per 15-min visit is based on the 10-month salary of $62,000 plus 7.5% for FICA, 6% for pension, and $10,600 for healthcare, or a 30.6% fringe rate. The total salary and fringe is $80,970 for 7 h per day for 192 days or 1,344 h. The nurse cost is therefore $60.25 per hour or $15.06 per 15-min visit. The opportunity cost of the school nurse time is lower than the budget impact of running the program because each school must have a fulltime nurse and nurse assistant to run the program. However, when the nurses were not providing telehealth services, they were providing other health services to the school. Without additional information on total healthcare utilization, students triaged to a telehealth consultation with a physician were assumed to have gone to a physician outside of school. Therefore, the cost of the physician time was not included.
All benefits (i.e., parent time for informal care, absences, and additional class time missed) were converted into a monetary value. The value of a lost school day was estimated based on the $10,280 annual cost of education divided by 180 school days, or $57.11 per absence. It was assumed that a parent or other caregiver would need to provide childcare and would miss 8 h of work. We used a human capital approach to valuing the missed work time as recommended by the Second Panel on Cost-Effectiveness in Health and Medicine (Nyman, 2018). Using this approach, we estimated the cost of productivity losses due to either work absence or displacement of unpaid work time in order to care for a child who is absent from school or requires medical visits using the mean hourly wage of the population. The 2016 mean wage for the county from the Quarterly Census of Employment and Wages (U.S. Bureau of Labor Statistics, U.S. Department of Labor) was inflated to 2017 dollars. | Assuming 2,000 h of work per year and a mean hourly rate of $32.90, the value of the parent or caregiver time per day of absence was estimated to be $263.20. The combined value of the missed school day and parent time was $320.31. We assumed that teachers would have to spend two additional hours to manage make-up work per absence. With a mean 2016 wage for elementary school teachers in Maryland of $64,970, assuming a 2,000 h work year and a 30.6% fringe rate, the two hours of teacher time cost of $85. Combined with the teacher time, the total cost per absence was $405.16. It was assumed that parents would have spent 2 h taking their child to another health provider and that they spend 15 min on the telehealth visit, for a net savings of 1 h and 45 min, saving $57.58 in time costs. The total cost of the health services and the cost savings from reduced parental time and absence time were summed to estimate the net cost per student in each program. The cost-benefit of telehealth was estimated in 2021 using SAS 9.4 (Cary, NC) based on data collected from 2014–2018.
Enrollment in the telehealth program began at 28% (n = 633) during the half-year roll-out in the spring of 2015. Enrollment increased to 36% (n = 1,144) in the 2015–2016 school year and 45% (n = 1,522) in the 2016–2017 school year. Enrollment rates varied from 34% to 60% across the six schools in the 2016–2017 school year. Utilization increased each school year from 94 (January 2015–June 2015) to 150 (SY 2015–2016) to 217 (SY 2016–2017). In SY 2016–2017, of the 178 students who utilized telehealth services students, 84% (n = 149) participated in one visit, 11% (n = 19) participated in two visits, and 6% (n = 10) participated in three visits. Diagnoses (n = 226) from the 217 visits in 2016–2017 are presented in Table 1. Diagnoses were recorded with ICD-9 codes, with 33 conditions spanning the standard complaints for primary care visits in this age group, including the following: ear (26%), throat (21%), eye (18%), skin (13%), asthma (9%), nose/sinus (5%), pain (5%), and fever (3.5%). Students utilizing telehealth services had a 95% adjusted return to class rate (students requiring exclusion as per school district policy were removed from the calculation) from visits (n = 367) during the 2015–2017 school years, compared to the estimated 75% for all health suite visits prior to program launch.
The school district dataset contained 26,416 observations across three school years (2014–2016). Observations were excluded where students transferred schools (n = 95), did not complete the whole year (n = 4,020), did not have absence data from 2014 (n = 4,605), or had duplicate records (n = 4,928). Fall 2014 absences and visits were used as control variables, but were excluded (n = 5,604) from the outcome dataset. The final sample included 7,164 observations from 4,203 students in SY 2015–2016 and/or SY 2016–2017. Demographic characteristics are presented for the analytic sample in Table 2.
Student absences and health suite visits for the 2015– 2017 school years are presented in Table 3. Absences were 7–8% higher in students not enrolled in telehealth in SY 2015–2016 (7.20 vs. 6.64 days) and SY 2016–2017 (7.81 vs. 7.32). Total health suite visits were not consistently different across groups (Table 3). In the adjusted negative binomial regression model controlling for fall 2014 health suite utilization and absences and demographic variables, students enrolled in the telehealth program were absent 7.7% (p = 0.025; 95% CI: 1.0%, 14%) fewer days per year than nontelehealth students. The full regression is in Appendix Table 1. Based on the mean absences in the non-telehealth students in SY 2016–2017 of 7.81 days, this 7.7% relative reduction resulted in a 0.60 day (95% CI: 0.08, 1.09) reduction in absences.
Program operating costs are presented in Table 4. Operating the program in 6 schools for 1,522 enrolled students was estimated to cost $189,122 in the 2016–2017 school year. Equipment and supplies accounted for $115,059 (61%) of the total cost. The majority of the equipment costs were from the purchase and maintenance of the telehealth equipment at each school and hosting fees for the service. Based on the 217 visits in the most recent year, nurse time accounted for only $3,268 (2%) of the total operating costs. A scenario analysis was conducted using updated telehealth licensing fees, which were reduced substantially in the 2018–2019 school year (Table 4). This reduced total program costs by 14% ($27,000) to $162,269.
Using our estimate of a 0.60 day reduction in absences due to telehealth enrollment and the $400.15 benefit per absence averted, telehealth resulted in annual societal savings of $372,500 (95% CI: $47,921; $674,984). The program saved an additional $12,495 due to reduced parent time for the 217 visits. The program led to an estimated total benefit of $384,995 (95% CI: $60,416; $687,479) and an annual net benefit of $195,873 (95% CI: −$128,706; $498,357). In the scenario analysis with lower telehealth hosting and licensing fees, the program was estimated to have an annual net benefit of $222,726 (95% CI: −101,853; $525,210).
Enrollment in an elementary school-based telehealth program was associated with a reduction in absences from school. The savings in parent care time and increased school attendance from this reduction led to substantial societal cost savings.
Additional research is needed to understand how school absences were reduced by the current acute care telehealth program and whether enhancing the chronic condition management model would enhance the effects. McConnochie et al., (2005) estimated that introducing telehealth in childcare centers in an urban setting resulted in a 63% reduction in absences due to illness. The authors hypothesized that the large reduction in absences may be explained by the ability to reduce mandatory exclusions from childcare due to illness by assessing the child and providing a safety certification during the childcare day. This study found a similar effect in elementary school students, with an increase in the adjusted return to class rate from 75% in standard health suite visits to 95% with telehealth.
This is one of the first studies to present program operating costs or a cost-benefit analysis of a telehealth-exclusive SBHC program. On average, the savings in parent and child time more than offset the cost of running the telehealth program. However, uncertainty around the absence estimate caused the cost-benefit estimate to vary from a benefit of $357,000 to a net cost of $139,000, highlighting the need for additional research. A recent Community Guide systematic review identified 15 studies that identified the cost of operating SBHCs, but only 3 that provided both costs and benefits (Ran et al., 2016). These studies found that SBHCs led to net benefits across a range of perspectives, including healthcare payer and patient. While we did not have access to medical claims data needed to estimate reductions in total healthcare expenditures, our study builds on the SBHC economic literature by analyzing the telehealthexclusive SBHC model and by quantifying the value of preventing absences, which was not included specifically in the Community Guide systematic review or key studies that estimated healthcare costs effectively (Guo et al., 2010; Ran et al., 2016).
The COVID-19 pandemic will likely lead to permanent increases in the adoption of telehealth in both traditional SBHC models and among schools launching telehealth-exclusive SBHCs (Sullivan et al., 2021). As telehealth services move towards wider adoption, evaluations focusing on both program costs and societal costs and benefits as well as comparisons to other SBHC delivery models utilizing telehealth for some services will be critical for informing local decision-makers balancing tight budgets and high student and family needs. These analyzes should address how the critical role of school nurses as a trusted source of care in schools and a bridge to other services can be enhanced with the right telehealth services and protocols (Leroy et al., 2017). The telehealth-exclusive SBHC will not function effectively if schools do not have a full-time nurse, which fewer than half of public elementary schools and only 18% of schools in rural districts reported (Willgerodt et al., 2018). One in five public schools in the United States (and one in three rural schools) reported having no paid nursing staff (Willgerodt et al., 2018). In our scenario analysis, recent changes in telehealth licensing and hosting fees were incorporated, which reduced total program costs by 14%. The majority of the operating costs in this study were fixed at either the school or district level. However, only 11% of students enrolled in the program utilized it in SY 2016–2017. Increased enrollment and utilization would lower the average cost per visit or per enrolled student.
Reductions in copayments or other fees for parents were not included in the overall estimate of the societal costbenefit of the program because the costs are instead being paid by the provider. However, because 80% of telehealth visits were provided for free, families saved money compared to using care from their normal providers that likely required a copayment. Of the 217 visits in SY 2016–2017, 174 had no copayment. Presenting these cost savings in addition to parental time savings is important for communicating the value of the program to parents as well as administrators and county executives who are responsive to parental input.
The primary limitation of this study is the lack of randomization, which reduces the internal validity of the study. However, health suite utilization and absences prior to telehealth implementation as well as a range of student sociodemographic characteristics were included as control variables in a quasi-experimental design that addresses many of the external validity limitations of RCTs for use in economic evaluation. The impact of telehealth enrollment on total healthcare expenditures could not be estimated due to a lack of data on healthcare received outside of the school setting. Future analyzes may consider linking records to students in Medicaid or other payers or health systems with high coverage in the school catchment area, as was done in an analysis by Guo et al. (2010). The impact of telehealth enrollment on student health outcomes were also not included in the analysis due to lack of data. However, student absence data are readily available to schools, are a close proxy for student illness, and have direct bearing on schools’ educational mission. Finally, while this is the first cost evaluation of the societal costs associated with an elementary school telehealth, assumptions regarding the time costs for parents or other guardians related to telehealth, or physician visits, and absences were needed to estimate nonpayer costs. In line with costing recommendations, (Drummond et al., 2015) arbitrary uncertainty was not added to these estimates or to any of the direct program costs.
Implementation of telehealth services within SBHCs was associated with a significant reduction in school absences. On average telehealth resulted in a net benefit to society due to reductions in parental missed work and child school absences. Enrollment and utilization remain a challenge to maximizing the value of telehealth services provided in SBHCs.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: ML, OAP, and RS were supported by an evaluation contract from Howard County, MD. JD, SH, and KW were supported as part of their work for the Howard County, MD, Health Department and Howard County, MD, Public Schools.
Michael W. Long https://orcid.org/0000-0002-3953-3424
Kerrie Wagaman https://orcid.org/0000-0002-3402-5746
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Michael W. Long, SD, is an assistant professor in the Department of Prevention and Community Health at the Milken Institute School of Public Health in The George Washington University.
Sharon Hobson, MSN, is the administrator of the School Based Wellness Center program at the Howard County Health Department.
Jacqueline Dougé, MD, is a pediatrician at the Pediatric Center of Frederick and the former medical director of the Bureau of Health Services in the Howard County Health Department.
Kerrie Wagaman, RN, is the director of Health Services at Howard County Public Schools.
Rachel Sadlon, MPH, is an associate director of Research and Evaluation at the Center for Health and Health Care in Schools at the Milken Institute School of Public Health in The George Washington University.
Olga Acosta Price, PhD, is an associate professor in the Department of Prevention and Community Health and director of the Center for Health and Health Care in Schools at the Milken Institute School of Public Health in The George Washington University.
1 Center for Health and Health Care in Schools, Milken Institute School of Public Health, the George Washington University, Washington, DC, USA
2 Health Department, Howard County, Columbia, MD, USA
3 Public Schools, Howard County, Ellicott City, MD, USA
Corresponding Author:Michael W. Long, SD, Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, 950 New Hampshire Ave NW, Washington, DC 20052, USA.Email: michael_long@gwu.edu