By Kevin Truong, MedCity News | February 24, 2019
Companies, health plans and providers are increasingly looking at delivering care at schools, where children spend most of their waking hours.
There isn’t a hospital, a medical clinic or even a decent grocery store nearby Robla School District in Northern Sacramento. Additionally, regulations dictate that nurses cannot administer even over-the-counter medication without a doctor’s order to students complaining of symptoms.
That poses a challenge in accessing healthcare for the school district’s roughly 2,000 students who range from pre-school to sixth grade—and 93 percent of whom qualify for the free and reduced lunch program.
This capability has been enabled by Hazel Health, a San Francisco-based digital health startup providing telehealth services to students in concert with school nurses at no additional cost to families. Hazel Health employs its own telemedicine clinicians who provide care to students at district schools.
The company and many of its VC-backed counterparts are part of a trend of digital health companies tackling student health that may represent a potential opportunity for investors while also achieving social good.
Within this broader movement, schools function as front line care delivery sites for pediatric care, preventive health education and chronic care management.
Hazel Health CEO Josh Golumb previously led on-site workplace clinic company Paladina Health. He sees parallels in delivering care where students spend a majority of their day and helping to stem chronic disease before it develops.
“We essentially create a virtual health clinic in a school setting,” Golumb said in a phone interview. “We can deal with the kind of low acuity stuff that keeps kids out of school that can lead to an avoidable ER visit and focus on getting the child on a treatment regimen and back to class.”
While some districts have introduced on-site clinics, the resources necessary to build out these are out of reach for many schools. Among lower-income students, primary care often takes the form of an expensive visit to urgent care or the emergency department which tacks on additional mental and financial hardship for parents forced to miss work to pick a child up from school.
“First and foremost our job is to educate these children and give them the tools they need to be successful. But what we’ve seen over time is the obstacles presenting themselves in the lives of these children keep getting in the way of the work we’re trying to do,” said Robla School District Superintendent Ruben Reyes in a phone interview. “Because our schools really are the center of the neighborhood it’s starting to make sense that we might bring those services here.”
Keeping students in the classroom
Hazel pitches its products to districts who are looking to improve general student health and attendance levels, which are often tied to funding. Besides the budgetary issues, chronic absenteeism is also correlated with lower rates of graduation and higher rates of incarceration.
According to the company, around 90 percent of students returned to class after seeing a Hazel provider. The 25-person startup serves more than 10,000 students across California and Arizona.
Golumb said Hazel works hard to underscore the importance of existing school staff and administrators who may be skeptical of handing over care responsibilities to a Silicon Valley tech startup. The company touts its services as extending the capabilities and reach of school nurses who are already stretched-thin. According to data from the National Association of School Nurses, California has one school nurse for every 2,240 students.
For Robla School District nurse Judy Allen, who rotates throughout the district’s six schools, the introduction of Hazel involved education about the use cases of telemedicine and collaboration on how best to implement the technology at the district.
“When you’re the lone school nurse there’s only so much you can do,” Allen said in a phone interview. “I like having the contact with other practitioners in a collaborative way to help figure out how to treat the student.”
She added that having additional clinical staff adds weight to the medical advice provided to parents in the case of more serious conditions.
There are a number of unique challenges to delivering care to minors in a school setting. Alongside HIPAA, which guards personal health information, administrators and companies must also contend with FERPA, a federal law which protects the privacy of student education records.
Use of this care delivery technology often also relies on affirmative consent from parents, which can be difficult to receive in communities mistrustful of certain authorities or institutions. For example, in the case of areas with large populations of undocumented immigrants.
Hazel tried to overcome this barrier by giving parents the ability to consent to care when their child needs to access the company’s services.
Making schools a healthcare ‘touchpoint’
Student medical records are mirroring larger health IT trends and moving from paper to the cloud with platforms developed by companies like Magnus Healthand SchoolDoc.
This technology helps to track and help schools better track and collect medical records like immunizations, allergies and emergency contacts.
While features may include communication with parents about health issues or tracking concussions on the football field, for the most part these tools work to reduce risk and liability for schools. Increasingly though, stakeholders like state health plans and health systems are seeing school-based healthcare as a successful model to provide care outside of a traditional clinical setting.
New York-based startup CareDox started out in 2010 as a student health record system called MotherKnows but has branched out into on-site school services like flu vaccinations, wellness programs and on-campus chronic disease management. The company has raised more than $26 million in funding since its founding.
Earlier this year, CareDox announced two major collaborations with Boston Children’s Hospital and Colorado Children’s Hospital to help students better manage conditions like pediatric asthma. Asthma is one of the most common pediatric chronic diseases and one of the top reasons for health-related absences. The condition is also generally not adequately controlled among lower-income patients, leading to more frequent and severe flare-ups.
The company partners with Colorado Children’s Hospital to use CareDox school districts as a distribution pathway for the provider’s expertise in treating pediatric asthma in schools.
That collaboration aims to train students and school nurses on best practices in managing asthma and using treatments like inhalers at the more than 7,000 schools across the CareDox network. It also helps schools triage higher risk students who may require more follow-up resources.
“The school nurses and school staff see these kids, can create care plans and can help with education. That may seem basic, but if families aren’t getting it and don’t have access to it can create all kinds of problems,” CareDox President Tony Boselli said in a phone interview.
“We’re in the schools, we’re part of the schools and so we can make sure in real time that all the data is being collected and all the proper information is being communicated back to the student and the family.”
Robin Deterding, director of the Breathing Institute at Children’s Hospital Colorado, said schools can function as a “structuring touchpoint” for pediatric asthma patients.
“The CareDox system provides a kind of scaffolding for the school nurse or school staff to interface with a healthcare issue. Schools need to step forward in helping students to manage their chronic disease because the kids in their environment and they need to know what resources to provide that child,” Deterding said.
“Over six million kids in the country under 18 have asthma and over half of those will destabilize once or more during the year, missing school to be in the ER or to be in the hospital. That’s a huge cost for both care and indirect costs from missed schools days and missed work.”
As opposed to the majority of student health record system companies, which sell directly to schools, CareDox’s business model is dependent on working with health plans and Medicaid programs to guard against some of the instability stemming from school budgetary fluctuations.
In a nod to the difficulty in charging schools directly for care delivery services, Hazel said it is working with commercial and government payer programs on risk-share models to help districts defray the cost of its technology platform.
Initially, CareDox is targeting the student Medicaid population with their more intensive care management programs, but is hoping to expand to commercial payers as well.
Much like the transition to EMR systems by hospitals, there is enormous promise in digitizing the kind of medical information that formerly existing only in filing cabinets.
Gaining high level insight into larger health issues on campuses allows for better decision making about investment and resource allocation. Examples mentioned by school administrators include pinpointing students who need additional community or health resources and a better understanding of how to direct staffers to best meet student health – as well as educational – needs.
Treating the whole child
Howard Morgan, the chairman of VC firm B Capital Group and an angel investor in CareDox said he was excited by the prospect of opening a front door to primary care at the place where 57 million children spend most of their waking hours.
“That’s a huge market where we could do well while doing good,” Morgan said in a phone interview. “We want to be the platform that gives them the access point and the electronic medical record and makes it easy for the schools to eventually add on tools like telehealth and digital therapeutics.”
Behavioral health looks to be one particular area of focus in which where this type of school-based primary care will advance in 2019.
Boselli said CareDox is in conversations with its provider partners to develop a framework for a behavioral health management program to offer to the schools it serves.
Research in the Journal of Developmental & Behavioral Pediatrics has shown that more than 1 in 20 school-age children suffer from anxiety and depression. That number goes up among vulnerable student populations or those diagnosed with another chronic disease.
Researchers and law enforcement officials have pointed to the increased investment in school-based behavioral health resources as being particularly urgent in the wake of the epidemic of school shootings at schools across the country.
On its platform, Hazel is developing a program to provide telehealth counseling and behavioral health services to its district customers.
“For a lot of the frequent fliers in the clinic that come in regularly for different issues, the underlying issues ends up being more mental health problems, perhaps manifesting physically,” said Hazel CTO and co-founder Nick Woods.
“We are identifying more and more of these students and putting more protocols in for screening to help catch people early and guide them towards resources that might be available.”