However, Cook Children’s School-Based Virtual Health Program is helping school nurses and parents ease some of that chaos.

“I see the benefit for my own family,” said Erwin, an LVN, IBCLC, and virtual health nurse coordinator with Cook Children’s.

Nurses in the Celina Independent School District now join 14 other school districts in offering virtual health appointments, with no upfront cost, through the school nurse’s office. A parent or legal guardian must register and consent before the visit.

The virtual health services can help diagnose:

• Earaches
• Fevers
• Coughs and colds
• Skin rashes
• Minor skin infections
• Abrasions/cuts/scrapes
• Sore throats
• Flu-like symptoms
• Pink eye
• Head lice

Autumn Morris, an APRN CPNP-PC and a virtual health nurse practitioner, met with Celina ISD nurses to train them on the program before the school year. Each campus nurse is provided with a stethoscope and an otoscope to use during virtual visits to help with diagnoses. Each item plugs into a laptop, allowing Morris to see inside a child’s ear and listen to their heartbeat, for example. In addition, each campus nurse is trained and certified to administer a flu and strep test if needed during the visit.

“It’s nice because then we can get the results right there,” said Allycia Cundiff, Celina ISD lead nurse.

Cundiff looks forward to the partnership and the impact it will have on the community. Morris will be able to determine if a child needs to be sent home or if they can stay in class, helping reduce absences.

Erwin says program data shows 65% of visits are due to a sore throat.

“We meet you where you're at because a lot of times it's really hard to get off work when your kid is sick,” said Morris.

Parents can choose to attend the virtual visit. Following the appointment, Morris will contact parents with information about the visit and post-care instructions. If a child must be sent home, an excuse note is sent directly to the school. A copy of the visit is also provided to the child’s pediatrician. 

Erwin explains that the virtual appointment does not replace a child’s primary care pediatrician but is a collaborative effort. Morris says the line of communication with the pediatrician can help determine if a child may need to see a specialist. 

“We want them to have a primary care physician (PCP) placement, and if they don't have that, we work hard to find them one with Cook Children's,” said Erwin.

Once the visit is completed, Cook Children’s will bill the parent’s insurance provider.

A visit to the nurse’s office

“Kids like it, too, because they think the technology is cool,” said Erwin. “They get to come in, they get to see Autumn on the screen and they get to talk.”

Morris works with more than 100 schools, providing care to them. She and Erwin lead the training with all district nurses in the program.

“I want them to know that I'm not just the provider who's seeing that kid at that moment, but I'm a resource to them (nurses) so they can reach out to me if there are any issues or concerns,” said Morris.

The program has been in place for eight years. Morris describes the partnership as the school nurses being her "hands" as she diagnoses a child's illness. If additional testing or care is required, she is able to refer the child to a Cook Children's Urgent Care or Cook Children's Medical Center Prosper, just a short drive from Celina.

“We always say, you don't just get me, you get a giant hospital system attached to me,” said Morris. “We are passionate employees of the system but we are passionate parents who love our kids.”

It is that confidence and reassurance that makes Cundiff excited for the partnership, not just as a nurse but as a parent herself.

 “We have a lot of parents that work for the district and it is really hard to leave work, especially if you're a teacher,” explained Cundiff.

Anatomy of a visit

A typical visit can last anywhere from two minutes to five minutes. Children will present themselves at the school nurse’s office, and a nurse will determine if a virtual visit may be helpful. If so:

• A parent or legal guardian is contacted for consent.
• The nurse will request a visit with Morris.
• The campus nurse will collect vitals.
• Virtual visit begins

Celina ISD began school on August 13. Parents can register for the program online.

Widespread change due to the COVID-19 pandemic has swept the nation, which has left many parents struggling to keep essential appointments with, not only their physicians, but with behavioral health specialists as well. Parents are now questioning the safety of the world beyond their windows and this has led parents, as well as psychologists and psychiatrists, to the use of telemedicine.

While Cook Children’s launched the telemedicine program in 2004 before the pandemic gripped the United States, this unprecedented time has pushed the world to embrace telemedicine like never before. While many parents and behavioral health specialists opted to continue in-person visits, parents like Patti Stephens persistently waited for the opportunity.

“Even before the pandemic began, I had hoped to be able to utilize telemedicine when we moved in October 2018. I knew this move would be temporary, so I wanted the continuity of care,” Patti said. “Unfortunately, we didn't qualify for telemedicine services for psychiatry so I drove to Fort Worth for appointments or for behavioral therapy.”

Patti’s family of four children has made countless trips from their home in West Texas to various Cook Children’s locations since 2002, from one child in the NICU to annual well-child visits to family therapy visits. When Patti’s family was finally able to begin using telemedicine, it allowed their family extra time, both in commuting and rounding up all four children at times for one appointment. With telemedicine, Stephens said her children found comfort in being in their own environment and she found flexibility in being able to schedule an appointment whenever she needed.

When the pandemic made it to Texas, Cook Children’s physicians quickly realized telemedicine would need to move to the forefront of their care delivery. Similar to some parents, physicians had to adapt quickly and learn how to use this technology in a way that would benefit each patient.

“When I heard we were going to utilize telehealth, my initial concern was my lack of experience and confidence in using this approach. I became anxious about how to meet the needs of my families best,” Laura Wright, LPC-S Family Therapist, said. “Therapeutic relationship is foundational for therapy, and I was concerned that would be lost in translation using telehealth. I wondered if my patients would be able to focus and attend to sessions in their home settings with all of the potential distractions.”

Concerns around telemedicine faded as patients began to flourish in the comfort of their homes. Parents and physicians may have experienced a learning curve; however, young patients took to the new technology quickly.

“I found rapport to be better unexpectedly. Patients would excitedly show their room or pets, and I felt I knew them better,” Hari Kumarasen, M.D., a psychiatrist at Cook Children’s, said. “It gave me insights into the patient’s personality. Telehealth allowed me to make observations about the child, seeing them in their environment, which I wouldn’t have otherwise been able to make. I also found my anxious and scared children and teen patients are more chill in their own environment.”

Telemedicine allows for long-distance patient/physician relationships, and offers parents options for non-emergent questions if a patient is traveling or not able to make an office visit.

“I have long felt that teletherapy should be an option for both patients and therapists. Especially for parents who have multiple children in therapy. It is so much easier to make and keep appointments via telemedicine,” Patti said. “Also, if we have established a relationship with a particular provider and either the provider or family moves further away, we don't have to start over with building a relationship with someone new.”

When the world begins to feel relief from COVID-19, patients and physicians alike are hoping to incorporate telemedicine into their routines. The ease of access for healthcare has created a positive outcome from an outbreak that has affected society so negatively.

“This is something I would absolutely desire to continue using, if not solely, at least in part. The lack of a stressful commute has been beneficial to my well-being, sparking newfound enthusiasm and creativity in my work,” Stephanie Golden, LPC Family Therapist, said. “As for a majority of my clients, participating in a familiar, safe setting called “home” seems to facilitate a willingness to engage more readily and thoroughly.”

At the beginning of the COVID-19, insurance covered telehealth appointments because patients could not keep their appointments in person. As the pandemic continues, more providers are returning to pre-COVID payment methods, meaning more companies are asking people to pay out-of- pocket for virtual visits. That leaves those who have benefitted from the telehealth concerned that it will go away or become costly for patient families who need it most.

“I am very concerned that we will lose the ability to conduct telehealth services due to insurance coverage limitations. It has proven to be beneficial for many of our patients, especially during this time of a global health crisis with the highly-contagious pandemic,” Golden said. “It certainly is advantageous for parents, giving some peace of mind about keeping their children in a safe space, removing the burden of taking their children away from the classroom and critical learning, and easing the stress of transporting them to and from the counseling office setting.”

The introduction of telemedicine has given families more access to health care focused on the patient experience and allows us to reach a child no matter where they are in the state of Texas. Physicians and health care providers’ willingness to adapt during the pandemic has raised the bar for healthcare delivery systems.

“Several of my patients and parents have shared the hope that telehealth will continue to be offered/available, noting the convenience of the service,” Wright said. “Distance for our remote families, lack of transportation, multiple children’s schedules to juggle, school, commuting, and work are all barriers to mental health treatment. Telehealth breaks down those barriers to reach these families.”