Abstract
The coronavirus disease 2019 (COVID-19) pandemic forced schools to close in spring 2020, affecting the ability of school-based health centers (SBHCs) to serve youth and families who relied on their services. This preliminary study aimed to understand the implications of school closures on SBHC operations. Survey data were collected from a convenience sample of representatives from 427 SBHCs, representing approximately one sixth of SBHCs nationwide. When schools closed in spring 2020, 77% of SBHCs closed temporarily, 5% closed permanently, and 12% remained physically open. Telehealth was a crucial strategy used to continue delivering essential services. The percentage reporting any telehealth service offering before and after school closures increased by over 200%. Yet they also reported challenges, including financial and policy restraints. Many SBHCs that closed temporarily did so because their host schools closed, suggesting that making arrangements to remain open if a similar situation to the COVID-19 pandemic should arise might be beneficial. SBHCs are a proven cost-effective model to deliver health care in resource-limited communities. These preliminary study results indicate that SBHCs maintained service delivery following school closures, though many faced challenges. Further research is needed to fully understand the pandemic’s impacts on SBHC service provision and health access and outcomes.
National data highlight declines in primary, preventive, and mental health services delivered to youth as a result of the coronavirus disease 2019 (COVID-19) pandemic, including 44% fewer child screening services and 44% fewer outpatient mental health services (Centers for Medicare & Medicaid Services, 2020). This translates to immediate and lifelong health implications for youth. Furthermore, social isolation, the economic recession (Golberstein et al., 2019), and family hardship and stress (Garfield & Chidambaram, 2020) during the pandemic may worsen existing mental health problems and increase new cases (Golberstein et al., 2019), heightening the need for comprehensive mental health services. More than half of youth who access mental health services annually do so at school (Ali et al., 2019). These numbers are higher among students from non-White and low-income families (Lipari et al., 2016).
Research shows that school-based health centers (SBHCs), health centers that operate on or near school campuses in predominantly low-income communities, are a cost-effective model to deliver essential physical, mental, and oral health services that improve health care access and outcomes for youth (Keeton et al., 2012; Knopf et al., 2016; Ran et al., 2016). Nationwide, more than 6.3 million youth and their communities have access to 2,584 SBHCs, located in 48 states, the District of Columbia, and Puerto Rico (Love et al., 2019). Most are operated by federally qualified health centers (51%) or hospitals/medical centers (20%; Love et al., 2019). Just under half serve urban communities, a third serve rural populations, and the remaining serve suburban communities (Love et al., 2019).
The pandemic forced schools to close in spring 2020, leaving many who rely on SBHCs with limited or no access to needed care. During nationwide listening sessions led by the School-Based Health Alliance (SBHA), SBHC representatives shared many challenges related to the pandemic and having to pivot services significantly, including closing temporarily or permanently, redeploying staff, discontinuing regular services to become COVID-19 testing sites, and shifting to only or principally telehealth care (Goddard et al., 2021). Building off these qualitative findings, this preliminary study used quantitative data to examine (1) changes in SBHC operations following spring 2020 school closures and (2) supports and challenges to SBHCs reopening or remaining open.
Method
Survey data were collected in August to September 2020 through an online portal. SBHA maintains a database with contact information for the 2,500+ SBHCs nationwide, described in detail elsewhere (Love et al., 2019). To encourage survey participation, SBHA sent three direct emails to database contacts. A convenience sample of 588 SBHCs responded. The final study sample (n = 427) excludes SBHCs that did not respond to a survey question about SBHC services and delivery modalities in fall 2019 (n = 121) and a question about the status of operations in spring 2020 following school closures (n = 40). This study focused on organizational practices and did not require institutional review board review.
The 15-question multiple choice survey asked SBHCs to report services, delivery modalities, and operations at three points in time: fall 2019, spring 2020, immediately following school closures, and fall 2020 plans. Qualitative research conducted in spring 2020 informed survey development (Goddard et al., 2021).
To address the first research question related to changes in SBHC operations, the primary outcome variables were respondent reports of (1) status of SBHC physical operations in spring 2020 following school closures, (2) in-person and/or telehealth services provided in fall 2019 and spring 2020, (3) estimated proportions of SBHC visits conducted via telehealth in fall 2019 and spring 2020, and (4) in-person and/or telehealth services intended to provide in fall 2020.
Telehealth was defined as interactions conducted via telehealth platforms, phone calls, messaging, or any other virtual platform, mirroring the telehealth flexibilities extended during the pandemic (Centers for Medicare & Medicaid Services, 2020). SBHC in-person and/or telehealth services include primary care, behavioral health, oral health, and/or vision services (see descriptions in Table 1). To define the status of SBHC physical operations following school closures in spring 2020, respondents were asked to report whether the SBHC physical site closed permanently, closed temporarily, remained open, and/or the SBHC offered services via telehealth. To assess the proportion of SBHC visits conducted via telehealth, respondents were asked to report estimates of the proportion of all SBHC visits, regardless of service type, conducted via telehealth.
SBHC Operations, Services, and Modalities in Spring 2020 Following School Closures and Supports and Challenges to Opening or Remaining Open in Fall 2020
Note. SBHC = school-based health center; COVID-19 = coronavirus disease 2019. “—” indicates measure not applicable among column sample.
Includes SBHCs that reported temporary closing in spring 2020 and SBHCs that remained physically open in spring 2020.
Respondents could select more than one response to this question.
Primary care includes comprehensive health assessments/exams; diagnosis and treatment of minor, acute, and chronic medical conditions; and referrals to and follow-up for specialty care. Services are delivered by physicians, nurse practitioners, and/or physician assistants. Behavioral health includes intake/assessments and individual or group therapeutic services provided by trained professionals. Oral health includes dental examinations/screenings, cleanings, and restorative services. Services are delivered by dentists, dental assistants, dental hygienists, and/or primary care providers. Vision includes vision screenings and corrective lenses. Services are provided by ophthalmic technicians, optometrists, ophthalmologist, and/or primary care providers.
Telehealth refers to interactions via telehealth platforms, phone calls, messaging/texts, and other virtual platforms.
To address the second research question, the outcome variables of interest were respondent reports of factors enabling physical sites to remain open in spring 2020 and challenges to reopening or remaining open in fall 2020. Enabling factors included having a separate community entrance, making arrangements with the host school, remaining open for COVID-19 testing, and/or remaining open for limited hours or services. Challenges included limited access to personal protective equipment; requirements to remain closed while the host school is closed; funding; staff redeployed, laid off, or furloughed; and/or other challenges described by respondents. The authors conducted bivariate analyses measuring frequencies of the outcome variables among the study sample in Stata (StataCorp LLC, 2019).
Results
Characteristics of the Study Sample
The study sample was evenly dispersed throughout the United States, with a slight majority in the South and Northeast regions. A majority of SBHCs in the sample were sponsored by a federally qualified health center or look-alike and employed a traditional delivery model (in which primary care is delivered at a fixed facility on a school campus) before the pandemic. Compared with SBHCs nationwide (Love et al., 2019), the sample was less likely to serve communities in large metropolitan areas or to provide access to families of student users or community members (data not shown).
Changes in SBHC Services, Operations, and Modalities Following Spring 2020 School Closures
When schools closed in spring 2020, 77% of SBHCs closed temporarily, 5% closed permanently, and 12% remained physically open. Among SBHCs that remained physically open (n = 53), fewer than half (43%) offered all the same in-person services that were provided in fall 2019. A majority (70%) offered in-person well visits, two thirds (66%) offered in-person sick visits, and a third (30%) provided COVID-19 testing (Table 1).
Over half of SBHCs (57%, n = 244) provided telehealth services following school closures in spring 2020. Of these SBHCs, a majority offered primary care (90%) or behavioral health (83%) and few, if any, provided oral health (9%) or vision (0%) via telehealth. Compared with fall 2019, the estimated proportion of SBHC visits conducted via telehealth increased from 3% to 79% among all sites offering telehealth in spring 2020 (n = 244) and from 2% to 40% among SBHCs that remained physically open at this time (n = 53). A majority (83%) of SBHCs physically open throughout spring 2020 (n = 53) offered primary care services via telehealth (Table 1), and SBHCs that did not offer telehealth in spring 2020 (n = 183) were more likely to close temporarily (86%) than others (data not shown).
Plans for in-person services in fall 2020 were not meaningfully different from in-person services offered in fall 2019 (Table 2). However, the proportion of SBHCs planning to offer at least one telehealth service increased from 26% to 84% among the study sample (n = 427) and from 25% to 91% among SBHCs physically open throughout spring 2020 (n = 53).
SBHC Services and Modalities in Fall 2019 and Plans for Fall 2020 a
Note. SBHC = school-based health center.
Fall 2020 reported as intentions (survey was administered just before the beginning of the school year).
Includes SBHCs that reported temporary closing in spring 2020 and SBHCs that remained physically open in spring 2020.
Respondents could select more than one response to this question.
Telehealth refers to interactions via telehealth platforms, phone calls, messaging/texts, and other virtual platforms.
Supports and Challenges to Reopening or Remaining Open
SBHCs able to remain physically open throughout the spring (n = 53) attributed this to arrangements made with the host school (60%) and having a separate community entrance (40%) (Table 1). Similarly, when asked to report challenges in reopening or remaining open in fall 2020, 60% of SBHCs that closed temporarily in spring 2020 (n = 330) were required to remain closed while the host school was closed (data not shown). A third (37%) of the study sample (n = 427) and more than two thirds (66%) of those that remained physically open throughout the spring (n = 53) reported financial constraints. About a quarter (24%) of the study sample (n = 427) reported furloughed, laid off, or redeployed staff as a challenge, and 16% had limited personal protective equipment. Open-ended survey responses described access to students, staff health concerns, and unsupportive policies and protocols as additional challenges.
Discussion
SBHCs save the health care system significant resources by providing more than six million students access to preventive and acute services (Knopf et al., 2016; Love et al., 2019; Ran et al., 2016). Sustaining their capacity to serve vulnerable communities is essential to responding to the health needs created and exacerbated by COVID-19 (Garfield & Chidambaram, 2020). SBHCs demonstrate a commitment to these populations and an understanding of the importance of continued care. Nearly all reported a shift to providing increased primary and behavioral telehealth immediately following school closures, and very few reported closing permanently. Notably, following school closures in spring 2020, eight out of 10 SBHCs that remained physically open offered primary care via telehealth, and SBHCs that did not offer telehealth at this time were more likely to close temporarily. This suggests that the telehealth delivery modality may have supported continuity of operations.
National data show that the demand for health services, and behavioral health care in particular, may increase as the pandemic continues (Centers for Medicare & Medicaid, 2020; Golberstein et al., 2019). While SBHCs’ plans to offer in-person services in the 2020–2021 school year were similar to in-person services delivered prior to school closures, they planned to offer significantly more telehealth services than had been offered prior to the pandemic. This shift is emblematic of SBHCs’ mission of providing quality health services in locations most convenient to their patients, thereby maintaining continuity of care. As schools reopen with various models of in-person and distance learning, SBHCs are dedicated to providing ongoing care and support to youth and their communities, although many face significant resource constraints.
Implications for Practice and Policy
National data indicate the drastic increase of telehealth following school closures did not outpace precipitous declines in essential primary and preventive services administered to high-need youth (Centers for Medicare & Medicaid Services, 2020). Before COVID-19, laws and policies presented roadblocks for SBHCs interested in establishing or expanding telehealth programs. For instance, telehealth parameters were defined by state Medicaid agencies and thus varied state-to-state. Some states required providers be licensed in the state where patients receive services, and some states limited the provider types that can deliver care through telehealth. These stipulations limited SBHC abilities to launch telehealth. Increased flexibilities for telehealth extended during the pandemic include the allowance of telephonic care, the allowance of the home as a reimbursable originating site, and the removal of cross-state licensing requirements (Centers for Medicare & Medicaid Services, 2020). These flexibilities must be bolstered to address long-term impacts.
Data from this study indicate funding as a threat to SBHC operations and sustainability. Many states provide direct or indirect funding to SBHCs; however, there is not a dedicated federal funding stream. Although states also face budget concerns, they must maintain their investment in SBHCs. Moreover, future COVID-19 relief legislation should prioritize support for SBHCs, given SBHCs’ ability to provide essential, accessible health services that can prevent future societal costs (Ran et al., 2016).
SBHCs that closed temporarily in spring 2020 largely attributed this to having to close while the host schools were closed, and most that stayed open did so through arrangements with schools. It may be beneficial for SBHCs to make arrangements with schools to remain open should a similar situation arise in the future to ensure clients receive uninterrupted care.
This study highlights SBHCs’ commitment to serving students nationwide throughout the COVID-19 pandemic and telehealth’s emergence as a crucial delivery strategy. Enabling policy solutions, increased funding, and additional supports are essential as SBHCs continue to support the health and well-being of students during and throughout the aftermath of COVID-19.
Limitations
The preliminary convenience sample may not be representative of SBHCs nationwide due to differences noted in characteristics of the sample compared with SBHCs nationally. The survey was administered at a time when SBHCs were overwhelmed by schools reopening, and sites that closed or redeployed/furloughed staff may be particularly underrepresented. Survey length was kept brief to respect respondent time, thus limiting information obtained. Finally, data were self-reported and missing in high proportions for some questions. Still, these results present a preliminary picture of the pandemic’s effects on SBHC operations and warrant further research.
