Effect of RISE Bundle implementation on school adoption of a student-centered return-to-learn program in Washington state

Abstract

BACKGROUND:

Appropriate concussion care in school is vital for full recovery, but school return-to-learn (RTL) programs are lacking and vary in quality. Establishing student-centered RTL programs may reduce disparities in RTL care.

OBJECTIVE:

To examine the effect of RISE Bundle (Return to Learn Implementation Bundle for Schools) implementation on high school adoption of a student-centered RTL program.

METHODS:

A convenience sample of fourteen (4 rural and 10 urban) small and large Washington (WA) State public high schools were enrolled in a stepped-wedge study with baseline, end of study, and monthly measures over the 2021–2022 academic year. Schools identified an RTL champion who led RISE Bundle implementation in 6-week steps. Concussion knowledge and impact of RTL program on concussion care were examined.

RESULTS:

Ten schools (71.4%) successfully completed RISE Bundle implementation and established a functional RTL program. Self-reported concussion knowledge from RTL Champions increased post intervention. Establishing RTL programs facilitated provision of tailored accommodations, and perceived variation and inequities in RTL care were reduced.

CONCLUSION:

RISE Bundle implementation proved feasible, supported the establishment of a functional RTL program, and perceived to reduce disparities in concussion care in rural and urban WA State public high schools of varying sizes.

Keywords

Youth concussion return to learn traumatic brain injury

1 Introduction

Nationally, youth concussions are a serious public health concern. An estimated 1.1—1.9 million sports and recreation related youth concussions occur each year in the United States (Bryan et al., 2016). Between 2016 and 2020, the estimated prevalence of U.S. 8th, 10th, and 12th grade students reporting at least one concussion during their lifetime increased from 19.5% to 24.6%, likely reflecting increased awareness and identification procedures (Veliz et al., 2021). Uniquely during high school, in Washington (WA) State’s Seattle Public School District, the sports-related concussion rate among high school students is estimated at 2.26% per academic year (Bompadre et al., 2014), and considering non-sports-related concussions the prevalence of concussions among high-school aged youth is likely greater.

Students with concussion experience physical, cognitive, sleep, and emotional symptoms that interfere with academic experience and school performance (Corwin et al., 2014; McCrory et al., 2017; Sady et al., 2011; Purcell et al., 2019), and high school-aged youth may have greater adverse academic outcomes compared to younger ages (Ransom et al., 2015). High school students who report one or more concussions have significantly lower grade point average (GPA) than those who report no concussion history (Lowry et al., 2019). As many as 70% of students with concussions have symptom resolution within 28 days but many have prolonged symptoms and there is a lack of consensus as to when students should return to school (Silverberg & Iverson, 2013; West & Marion, 2014; Zemek et al., 2016).

Return to school and school-based Return to Learn (RTL) programs aim to improve care and outcomes of students with concussion returning to the classroom. Students with concussion who return to the classroom without support, and those who remain out of school for an extended time following concussion, report longer lasting symptoms than those who are supported by a formal RTL program (Brown et al., 2014; Carson et al., 2014; Grady & Master, 2017). School RTL programs should consist of five essential components: (1) identification, screening, and assessment practices, (2) systematic communication between medical and educational systems, (3) tracking of children’s progress over time, (4) professional development for school personnel, and (5) outcome measures to assess academic success (O’Neill et al., 2017; Gioia, 2015). While all 50 states have adopted Return to Play (RTP) legislation, few states have formal legislation related to supporting RTL, including WA. Even among states with RTL legislation, significant variability exists, and few states include evidence-based RTL guidance (Potteiger et al., 2018; Thompson et al., 2016). In WA State schools, previous research suggests that children have unmet needs upon return to school after concussion, including lack of school policies, barriers to providing and receiving accommodations, and wide variability in communication patterns (Lyons et al., 2017). Due to the wide variability in RTL legislation, guidance, and provision of academic accommodations, students experience inequities in concussion management practices.

Despite the clear need to support evidence-based RTL in schools, there is little evidence as to which RTL program is best and how to best implement a school-based RTL program (O’Neill et al., 2017, Neelakantan et al., 2020). Many existing RTL programs contain the same key components (i.e., management approaches, outcome measurements, and accommodations) but lack clear policies, effective staff education on concussion symptoms, and use of best practices in stakeholder communication (Kemp & O’Brien, 2022; Fetta et al., 2021; McAvoy et al., 2020). In 2020, we reported our community-engaged approach to the development of a student-centered RTL plan for sports- and non-sports-related concussions that reduces disparities in RTL care (increases access to accommodations that are tailored to the student’s symptoms, standardize check-in process for all students, and standardized RTL implementation in schools), which we piloted in 13 WA public high schools and found high implementation fidelity, feasibility, and acceptability (Conrick et al., 2020). Following, in 2021, Philipson et al. reported that the use of the student-centered RTL plan that includes tailored accommodations proactively identified WA State students who require longer-term support (Philipson et al., 2021). The 6-week RTL plan and implementation process is now called the Return to Learn Implementation Bundle for Schools (RISE Bundle). In this study, we examined the effect of RISE Bundle implementation on school adoption of a student-centered RTL Program in WA State public high schools.

2 Methods

2.1 School recruitment

Public high schools in WA State with more than 50 students enrolled were eligible to participate; schools reporting existing RTL programs or policies were excluded. A list of WA high schools was generated from two educational agencies: the Washington Office of Superintendent of Public Instruction (OSPI) and Washington Interscholastic Activities Association (WIAA). High schools were sent an email invitation to participate, and the research team responded to schools who expressed interest in participation. Participating schools received a one-time payment of $800 upon full completion of the study in June 2022. The study was given exempt status by the Human Subjects Review Committee at the University of Washington, and Data Sharing Agreements were approved by each participating high school.

2.2 Study design

We used a convenience sample stepped-wedge study design during the 2021–2022 academic year. The study included three blocks (Block One based on readiness/willingness [n = 4]; Block Two [n = 6] and Block Three [n = 4] based on similarity of academic calendars). The three blocks were staggered by six weeks, with a new block of schools beginning the RISE Bundle every six weeks.

2.3 RISE Bundle (Return to Learn Implementation Bundle for Schools) intervention

The RISE Bundle is a six-week implementation strategy to establish a student-centered RTL program in public high schools and consists of the five RTL essential components (O’Neill et al., 2017; Gioia, 2015). As previously described, the RISE Bundle was developed iteratively using the Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009) and reflects input from clinician experts, rural and urban stakeholders, school staff, and integrates RTL evidence and implementation science principles (Philipson et al., 2021; Conrick et al., 2020). The RISE Bundle includes a (1) coached RTL program, (2) toolkit to track and guide concussion care of students, (3) concussion education for school RTL Champions, and (4) RTL program support. The RISE Bundle is designed to be managed and completed by a representative at the school, referred to as the RTL Champion. The RTL Champion could be any member of the school; medical experience is not required.

2.3.1 Coached implementation

The RISE Bundle includes a comprehensive milestone-driven set of documentation templates, guidelines, resources, and educational materials to establish a functional RTL program at the school. The RTL Champion is provided with action items they must complete throughout the six-week implementation period (Supplement Table 1). Monthly coaching was provided by one of the two study staff by videoconference or phone to answer questions and help facilitate RTL program establishment.

2.3.2 Tracking toolkit

The electronic and password-protected tracking toolkit guides RTL Champions through student specific RTL care to support sport- and non-sport-related student concussions reported to school personnel. Toolkit instructions include weekly check-ins and evaluation of symptoms; provision of symptom-tailored concussion accommodations; and scripted communications with students, parents/guardians, teachers, and healthcare providers. Students who report experiencing symptoms beyond three weeks are encouraged to seek medical care and referral for a formal school-based accommodation consideration. For students whose concussion symptoms resolve between weeks 1 and 3, RTL Champions complete the tracking toolkit when concussion symptoms resolve and when academic accommodations are no longer needed without further follow-up. Schools retain links between student identification and toolkit number; the research team does not have access to student identifiers.

2.3.3 Concussion education

Online concussion education for the RTL Champion and other school stakeholders are available by the Center on Brain Injury Research and Training (CBIRT; https://cbirt.org/). Previous randomized controlled trial and quasi-experimental studies have found the CBIRT online education effective in increasing knowledge of and application of effective strategies for working with students with concussion (McCart et al., 2020; Glang et al., 2019). RTL Champions complete the following eight educational modules: “How is Brain Injury Different than Other Disabilities?,” “Returning to School After Concussion,” “Curriculum Modifications vs. Accommodations,” “Academic Accommodations,” “Creating a Brain Injury Friendly Classroom,” “Positive Behavior Supports,” “Managing Behavior,” and “Collaborating with Parents” (https://returntoschool.org/training).

2.3.4 RTL program support

Structured support is provided to RTL Champions throughout the academic year for timely completion of RISE Bundle implementation tasks, use of the tracking toolkit (i.e., data entry instructions), and for all other RTL program inquiries through scheduled meetings and monthly coaching sessions.

2.4 Measures

2.4.1 School and RTL champion characteristics

Characteristics of participating schools and WA public high schools were collected from publicly accessible data sources. The number of students, number of teachers, average years of teaching experience, average class size, per-pupil expenditure, demographic distributions, and equity measures at each participating school were collected from report cards on the OSPI website as of September of 2021 (https://www.k12.wa.us/). School characteristics were based on data from the 2018–2019 school year to the 2020–2021 school year, depending on availability. Rurality was determined per the Washington Education Data and Research Center’s definition of distant schools (https://erdc.wa.gov/). All schools classified as large metro, metro suburb, mid-size, and urban fringe were classified as urban schools. The profession of the RTL Champion was collected via survey at the beginning of the school year.

2.4.2 Outcomes

2.4.2.1. Main outcome Timely completion of RISE Bundle implementation at 6 weeks and use of a tracking toolkit that provided student-centered accommodations defined successful establishment of a student-centered RTL program.

2.4.2.2. Implementation outcomes Completion rates for all 12 RISE Bundle tasks were determined for each school. The number of schools completing the tracking toolkit for students who reported concussion to school personnel was documented.

2.4.2.3. Self-reported concussion knowledge RTL champions reported how strongly they agree on nine concussion items that were developed by the study team and clinical experts including statements of confidence, knowledge, and receipt of training questions at the beginning (August 2021) and end of the school year (June 2022) using a five-point Likert Scale (1 = Strongly disagree; 2 = Disagree; 3 = Neutral; 4 = Agree; 5 = Strongly agree). A dichotomous variable was created to evaluate if RTL Champions agreed (self-report of Strongly Agree or Agree) or disagreed (self-report of Neutral, Disagree, or Strongly Disagree) with concussion knowledge statements. One concussion knowledge statement (“I have been trained in detecting concussion”) was excluded from analyses as it was outside the scope of the RISE Bundle and RTL program. RTL Champions are not responsible for detecting concussion.

2.4.2.4. RTL Program Assessment RTL Champions reported on how strongly they agree on three questions assessing effects of the RTL program at the end of the school year (June 2022) on a five-point Likert Scale (1 = Strongly disagree; 2 = Disagree; 3 = Neither agree nor disagree; 4 = Agree; 5 = Strongly agree). RTL program assessment questions included: “Do you believe the RTL program increased your school’s ability to provide appropriate concussion care for students?;” “Do you believe the RTL program reduced variation in concussion care at your school?;” and “Do you believe the RTL program reduced inequities in concussion care at your school?” A three-categorical variable was created to evaluate whether RTL Champions agreed (Strongly agree or agree), disagreed (Strongly disagree or disagree), or neither agreed nor disagreed.

2.5 Data analysis

Descriptive statistics were used to characterize RISE Bundle implementation and outcomes. For school-level data, continuous characteristics were displayed as mean and standard deviation, while categorical factors or questions were displayed as counts and percentages. We evaluated the number of schools who completed the 6-week RISE Bundle implementation process and the number of schools who used the tracking toolkit. We then compared the number of RTL Champions who self-reported they “agree” vs “disagree” on the concussion knowledge statements across the academic year and by RISE Bundle completion. Lastly, we examined the number of RTL Champions who self-reported they agreed on the three RTL program assessment questions. All research entries were independently completed by RTL Champions in the University of Washington’s Research Electronic Data Capture (REDCap) database (Harris et al., 2009). Statistical analyses were conducted in Stata/MP 15.1 (StataCorp, College Station, TX).

3 Results

Six hundred and ten WA high schools (69% of all WA public high schools) were sent an email invitation to participate, and 460 schools were successfully contacted, of which 38 (8.3%) responded to the initial email inquiry and expressed continued interest. When the study launched in September 2021, 18 schools were enrolled. Post study launch, four schools withdrew during the academic year due to large COVID-19 pandemic related workloads. During the 2021–2022 academic year, 14 WA State public high schools were enrolled. Student demographics of the 15,907 students enrolled in the participating 14 public high schools are similar to the 344,040 total public high school students in WA State (Supplement Table 2).

Table 1 shows study school characteristics by RISE Bundle implementation completion. Most enrolled schools were urban (71.4%), and most RTL Champions were school nurses (64.3%) followed by athletic trainers (21.4%) (Table 1). Ten schools (71.4%) established a functional RTL program, defined as completion of RISE Bundle implementation and use of tracking toolkit over the academic year (Table 1). Schools that did not complete the RISE Bundle implementation were more urban; reported larger student enrollment, class size, and number of teachers; and have more students that identify as Asian, Black or African American, Native Hawaiian or Other Pacific Islander, two or more races, and fewer students that identify as Hispanic or Latino (Table 1).

Table 1
Characteristics of 14 participating Washington State public high schools by RTL Program establishment, Washington Office of Superintendent of Public Instruction, 2020–2021 school year

Cohort Established RTL Program

Yes No

N = 14 n = 10 n = 4

Characteristics averaged across schools, mean (SD)

Number of students 1136 (726.1) 902 (712.7) 1721 (348.9)

Number of teachers 69 (36.8) 56 (34.4) 101 (17.9)

Average years of teaching experience 14.0 (3.9) 14.8 (4.3) 12.2 (2.4)

Average class size 16 (4.1) 15 (4.3) 18 (2.1)

Per-pupil expenditure 13989.3 (1577.7) 14122.7 (1865.1) 13655.8 (377.3)

Characteristics averaged across schools, mean percentage (SD)

Student gender, %

Female 48.9 (2.1) 48.9 (2.3) 48.9 (1.5)

Male 51.0 (2.1) 51.0 (2.2) 51.1 (1.5)

Gender X 0.1 (0.1) 0.1 (0.1) 0.1 (0.1)

Student race/ethnicity, %

White 56.2 (26.4) 55.7 (30.1) 57.7 (17.3)

Hispanic/Latino of any races 25.2 (28.0) 28.8 (32.5) 16.2 (8.8)

Asian 7.9 (10.1) 7.1 (9.6) 9.8 (12.4)

Two or more 7.1 (4.7) 6.0 (4.5) 9.7 (4.9)

Black/African American 2.5 (4.0) 1.8 (2.8) 4.2 (6.2)

Native Hawaiian/Other Pacific Islander 0.7 (1.8) 0.2 (0.3) 1.9 (3.4)

American Indian/Alaska Native 0.5 (0.4) 0.5 (0.4) 0.6 (0.5)

English learners, % 8.1 (11.9) 9.8 (13.8) 4.0 (2.6)

Low income, % 37.0 (26.6) 40.4 (28.6) 28.5 (22.1)

Graduate in 4 years, % 92.4 (5.3) 92.5 (6.2) 92.3 (2.6)

Characteristics per school, n (%)

Rural 4 (28.6) 4 (40.0) 0

Urban 10 (71.4) 6 (60.0) 4 (100.0)

RTL Champion role

Nurse 9 (64.3) 5 (50.0) 4 (100.0)

Athletic Trainer 3 (21.4) 2 (20.0) 1 (25.0)

Athletic Director 2 (14.3) 2 (20.0) 0

Teacher 2 (14.3) 2 (20.0) 0

Principal 1 (7.1) 1 (10.0) 0

	Cohort	Established RTL Program
Characteristics averaged across schools, mean (SD)
Number of students	1136 (726.1)	902 (712.7)	1721 (348.9)
Number of teachers	69 (36.8)	56 (34.4)	101 (17.9)
Average years of teaching experience	14.0 (3.9)	14.8 (4.3)	12.2 (2.4)
Average class size	16 (4.1)	15 (4.3)	18 (2.1)
Per-pupil expenditure	13989.3 (1577.7)	14122.7 (1865.1)	13655.8 (377.3)
Characteristics averaged across schools, mean percentage (SD)
Student gender, %
Female	48.9 (2.1)	48.9 (2.3)	48.9 (1.5)
Male	51.0 (2.1)	51.0 (2.2)	51.1 (1.5)
Gender X	0.1 (0.1)	0.1 (0.1)	0.1 (0.1)
Student race/ethnicity, %
White	56.2 (26.4)	55.7 (30.1)	57.7 (17.3)
Hispanic/Latino of any races	25.2 (28.0)	28.8 (32.5)	16.2 (8.8)
Asian	7.9 (10.1)	7.1 (9.6)	9.8 (12.4)
Two or more	7.1 (4.7)	6.0 (4.5)	9.7 (4.9)
Black/African American	2.5 (4.0)	1.8 (2.8)	4.2 (6.2)
Native Hawaiian/Other Pacific Islander	0.7 (1.8)	0.2 (0.3)	1.9 (3.4)
American Indian/Alaska Native	0.5 (0.4)	0.5 (0.4)	0.6 (0.5)
English learners, %	8.1 (11.9)	9.8 (13.8)	4.0 (2.6)
Low income, %	37.0 (26.6)	40.4 (28.6)	28.5 (22.1)
Graduate in 4 years, %	92.4 (5.3)	92.5 (6.2)	92.3 (2.6)
Characteristics per school, n (%)
Rural	4 (28.6)	4 (40.0)	0
Urban	10 (71.4)	6 (60.0)	4 (100.0)
RTL Champion role
Nurse	9 (64.3)	5 (50.0)	4 (100.0)
Athletic Trainer	3 (21.4)	2 (20.0)	1 (25.0)
Athletic Director	2 (14.3)	2 (20.0)	0
Teacher	2 (14.3)	2 (20.0)	0
Principal	1 (7.1)	1 (10.0)	0

Self-reported RTL Champion agreement with concussion knowledge statements at the beginning and end of the academic year by establishment of RTL program are shown in Table 2. At the beginning of the year, RTL Champion agreement on the eight concussion knowledge statements were generally low except for agreement that school accommodations improve outcomes for students with concussion (92%). RTL Champion agreement generally increased at the end of the academic year with the largest increases in knowledge of the different academic accommodations and of the objective of a RTL plan, and agreement of being trained in providing academic accommodations (Table 2). Larger increases in agreement on the concussion knowledge statements were seen among RTL Champions who successfully established an RTL program compared to RTL Champions who did not (Table 2).

Table 2

Self-reported concussion knowledge among participating RTL Champions by RISE Bundle completion at beginning and end of 2021–2022 academic year

	Cohort		Established		Not established
			RTL Program		RTL Program
	n = 14		n = 10		n = 4
	n (%)		n (%)		n (%)
	Start	End	Start	End	Start	End
I know a lot about concussions
Agree	8 (57.1)	13 (92.9)	7 (70.0)	9 (90.0)	1 (25.0)	4 (100)
Disagree	6 (42.9)	1 (7.1)	3 (30.0)	1 (10.0)	3 (75.0)	0
The objectives of a concussion Return to Learn plan are clear to me
Agree	6 (42.9)	12 (85.7)	5 (50.0)	9 (90.0)	1 (25.0)	3 (75.0)
Disagree	8 (57.1)	2 (14.3)	5 (50.0)	1 (10.0)	3 (75.0)	1 (25.0)
I have been trained in providing accommodations for students with concussion
Agree	4 (28.6)	10 (71.4)	4 (40.0)	7 (70.0)	0	3 (75.0)
Disagree	10 (71.4)	4 (28.6)	6 (60.0)	3 (30.0)	4 (100)	1 (25.0)
I have received a traumatic brain injury education to better identify and understand concussion symptoms
Agree	5 (35.7)	10 (71.4)	5 (50.0)	7 (70.0)	0	3 (75.0)
Disagree	9 (64.3)	4 (28.6)	5 (50.0)	3 (30.0)	4 (100)	1 (25.0)
I know the different categories of academic accommodations
Agree	3 (21.4)	12 (85.7)	3 (30.0)	8 (80.0)	0	4 (100)
Disagree	11 (78.6)	2 (14.3)	7 (70.0)	2 (20.0)	4 (100)	0
I am confident I can communicate concussion symptoms and accommodations to teachers and medical providers
Agree	7 (50.0)	12 (85.7)	5 (50.0)	8 (80.0)	2 (50.0)	4 (100)
Disagree	7 (50.0)	2 (14.3)	5 (50.0)	2 (20.0)	2 (50.0)	0
I feel confident in delivering school accommodations for concussion
Agree	7 (50.0)	11 (78.6)	5 (50.0)	8 (80.0)	2 (50.0)	3 (75.0)
Disagree	7 (50.0)	3 (21.4)	5 (50.0)	2 (20.0)	2 (50.0)	1 (25.0)
School accommodations improve outcomes for students with concussion
Agree	13 (92.9)	14 (100)	10 (100)	10 (100)	3 (75.0)	4 (100)
Disagree	1 (7.1)	0	0	0	1 (25.0)	0

Self-reported agreement on RTL program assessment questions among RTL Champions who successfully established an RTL program are shown in Table 3. Among the 10 RTL Champions, the majority reported that the RTL program increased their school’s ability to provide appropriate concussion care (90%) and reduced variation (70%) and inequities (80%) in concussion care.

Table 3

Reported agreement on RTL program assessment questions among RTL Champions who established an RTL program over the 2021–2022 academic year

	Schools with established
	RTL program
	N = 10
	n (%)
Do you believe the RTL program increased your school’s ability to provide appropriate concussion care for students?
Strongly agree or agree	9 (90.0)
Neither agree nor disagree	1 (10.0)
Disagree or strongly disagree	0
Do you believe the RTL program reduced variation in concussion care at your school?
Strongly agree or agree	7 (70.0)
Neither agree nor disagree	3 (30.0)
Disagree or strongly disagree	0
Do you believe the RTL Program reduced inequities in concussion care at your school?
Strongly agree or agree	8 (80.0)
Neither agree nor disagree	2 (20.0)
Disagree or strongly disagree	0

4 Discussion

The main finding of this study is that over the 2021–2022 academic year, RISE Bundle implementation established a student-centered RTL program in a diverse sample of WA state public high schools based on RTL Champion perceptions. We also found that RTL Champions increased their self-reported concussion knowledge over the academic year and that establishing RTL programs facilitated provision of student-centered RTL care while reducing perceived inequities and unwanted variation in concussion care based on RTL Champion self-reports. To our knowledge, this is the first study to report an effective implementation strategy for student-centered RTL care with an equity focus (symptom-tailored academic accommodations and standardized RTL program for all students with concussion).

In this study, larger schools in urban areas were less likely to complete RISE Bundle implementation and establish a functional RTL program. While this may seem counterintuitive because larger schools may have more resources, larger schools may also have more concussions compared to smaller schools, necessitating more time and resources for supporting students in an RTL program. In this study, one person at each school was appointed as the RTL Champion and was responsible for completing the RISE Bundle implementation processes and tracking toolkit tasks. Having more than one person responsible for RTL items could increase the likelihood that larger schools would establish an evidence-based RTL program (Sarmiento et al., 2019). Concussion management teams are one strategy that has been recommended, such as by the Center for Disease Control and Prevention HEADS Up educational materials on youth concussion (https://www.cdc.gov/HeadsUp/), to support RTL programs. However, they are costly in terms of personal time, and the effectiveness of their use has not been evaluated for outcomes in relation to programs such as the RISE Bundle.

Schools that had more students who self-identified as Asian, Black or African American, Native Hawaiian or Other Pacific Islander, or two or more races were less likely to complete RISE Bundle implementation and less likely to establish a student-centered RTL program. Although this finding could have important implications for resources in schools with higher student populations from minority groups, our school sample size was too small to significantly evaluate this comparison. Future studies with larger sample sizes are needed to evaluate RTL program establishment across schools with different student demographic compositions.

RISE Bundle implementation and establishment of an RTL program increased concussion knowledge among participating RTL Champions. At baseline, concussion knowledge was generally low, and while nearly all RTL Champions reported they agreed that school accommodations improve outcomes for students with concussion, less than a third agreed that they have been trained in providing accommodations for students with concussion, and less than a quarter agreed that they know the different categories of academic accommodation at baseline. These results reinforce our understanding that schools struggle to provide adequate concussion support and concussion education for school personnel (Lyons et al., 2017). At the end of the year, concussion knowledge generally improved with the largest improvements in knowledge of different academic accommodations, objectives of a RTL program, and provision of academic accommodations; these findings are not reported from schools without a formal RTL program (Fetta et al., 2021).

Our study found that the establishment of a RTL program increased school ability to provide appropriate concussion care based on RTL Champion perceptions, a finding consistent with prior work (Philipson et al., 2021; Lyons et al., 2017). There are two novel aspects to this study. First, the RISE Bundle provides student-centered RTL accommodations to students with concussion. Second, based on RTL Champion self-reports, the RTL program was perceived to reduce inequities and unwanted variation in concussion care at schools for students with concussion. These findings suggest that the implementation of a standardized evidence-based RTL program could promote equity in concussion care in schools and may reduce disparities in adverse outcomes among youth with concussion.

This study has strengths and limitations. The main strength is that this is the first study to provide evidence for an equity-focused implementation strategy for adoption of student-centered RTL programs in high schools. Our study population included a diverse (e.g., schools in rural and urban areas; schools across the size continuum) and similar sample to all WA State public high school students. Our ability to conduct this study during the COVID-19 pandemic suggests that schools need support establishing RTL programs, value the RISE Bundle, and prioritize concussion care. Successful implementation of the RISE Bundle during the COVID-19 pandemic suggests that RISE Bundle implementation is both feasible and acceptable. These features provide unique contributions and evidence that successful adoption of RTL in schools is feasible through intervention strategies like the RISE Bundle. The main limitation of this study is that we could not randomize participating schools to block allocation due to pandemic-related logistical challenges. However, a convenience sample stepped-wedge design allowed us to evaluate the feasibility of RISE Bundle implementation. Due to differences in school numbers, characteristics, and participation involvement between blocks (Supplement Table 3), we used descriptive statistics to present the effect of the RISE Bundle on RTL program establishment. While the number of study schools was small, we were able to successfully improve RTL care in some WA State public high schools, providing an important foundation for future work across the region.

5 Conclusions

There is an urgent need for schools to establish RTL programs that benefit students with concussion across the country (Potteiger et al., 2018; Thompson et al., 2016; Lyons et al., 2017). Understanding how to achieve this goal and establish student-centered RTL programs is important to improve RTL care and outcomes for students with concussion. Implementation of the RISE Bundle is feasible and can successfully establish a student-centered RTL program in rural and urban public high schools of varying sizes, potentially reducing inequities and unwanted variation in concussion care.

Funding

The Return to Learn project was supported by the Centers for Disease Control and Prevention (grant number R49CE003087).

Conflict of interest

The authors have no conflicts of interest to declare.

Footnotes

Acknowledgments

This study was supported by the Harborview Injury Prevention and Research Center and the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA. We thank the Return to Learn Project Advisory Board and Co-investigators, partners at foundry10 and Washington State Department of Health, as well as the school participants for their continued support for students with concussion and determination for advancing RTL in schools.

The supplementary files are available from .

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