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Reimagining the Role of School‐Based Health Centers During the COVID‐19 Pandemic

For the past decade, school‐based health centers (SBHCs) have become one important solution for increasing access to care for children from disadvantaged backgrounds in the United States 1, 2 This is especially critical given that children in underserved communities have higher rates of asthma, obesity, mental health disorders, and are less likely to receive routine care from community providers 1 With the onset of the COVID‐19 pandemic and the resultant nationwide K‐12 school closures, SBHCs have had to adopt alternate strategies to continue providing care to school children in need, with some not having the capacity to remain open at all 3

F or the past decade, school-based health centers (SBHCs) have become one important solution for increasing access to care for children from disadvantaged backgrounds in the United States. 1,2 This is especially critical given that children in underserved communities have higher rates of asthma, obesity, mental health disorders, and are less likely to receive routine care from community providers. 1 With the onset of the COVID-19 pandemic and the resultant nationwide K-12 school closures, SBHCs have had to adopt alternate strategies to continue providing care to school children in need, with some not having the capacity to remain open at all. 3 With the uncertainty regarding how schools will operate during 2021 and beyond, compounded with a ∼7% unemployment rate nationally and loss of employer-based health insurance for thousands of families, there likely will be an even greater need for school-based health services during the current, and possibly, the next academic year. Furthermore, during school closures, many students have not been accessing health services previously received either in the school setting or even in the community. For example, there has been a 21.5% decrease in immunizations for children age 18 or younger compared to last year. 4 As schools re-open, they will need to be prepared for a surge in demand due to delayed care. In addition, there likely will be other services that SBHCs will be called on to provide, including mental health services and helping to facilitate testing and care for potential COVID-19 cases.
As the national discussion is focused on how schools will operate during the pandemic, 5  important opportunity to lead the effort in supporting students' unmet health needs as their role in providing health services is needed now more than ever. To be successful, they must consider how to engage with parents, strengthen community care partnerships, and explore telehealth modalities to support student health care needs.

SBHC-PARENTAL COMMUNICATION/ENGAGEMENT
The COVID-19 pandemic has emphasized the necessity for SBHCs to consider strategies on how to ensure parental knowledge of their child's condition, treatment plan, and accessibility of community resources, especially when schools are closed. Parents will require more communication and knowledge than before, particularly because families might be hesitant about sending their children back to school without knowing about the school's infection control and risk mitigation policies.
Conceptually, SBHCs involve a different dynamic with parents and providers compared to the community-based pediatric practice. Not only is the school prominently featured as the location of care, but also the parent is not routinely present during clinical encounters. This poses a challenge of how providers and parents engage. Parental engagement is crucial to ensuring student adherence with health care recommendations. 6 In the past, decreased parental engagement and poor SBHC-parental communication have ben notable problems in SBHCs, leading to challenges with implementing care plans. 7 As schools re-open, SBHCs must consider robust methods for increasing parental engagement and effective parent-school communication. A multimodal approach to communication that involves phone calls, virtual school meetings, sending information home with children, along with email, may enhance parental communication and knowledge about their child's health. Encouraging parent involvement, when possible, during a clinical encounter also may help.

ENSURING CONTINUITY OF CARE WITH COMMUNITY PROVIDERS
For many families in disadvantaged communities, SBHCs are the sole source of their children's primary care. 2,8 Because over 80% of SBHCs deliver care from a fixed site on a school campus, 1 they are often closed during long school breaks and holidays. 8 Many pediatricians have voiced concerns about the potential fragmentation of care because SBHCs may not provide access to care when schools are closed. 8 The COVID-19 pandemic exacerbates the issue of fragmented care, with the closure of many SBHCS leading to potential gaps in care for families primarily dependent on school-based health services. Additionally, families may be uncertain about how and where to access care when SBHCs are closed. Because many parents that rely solely on SBHCs are often uninsured, 8 this may lead to an increase in utilization of urgent care and emergency services, at a time when COVID-19 is already straining our health care centers, or not obtaining necessary care at all.
As schools could continue to face intermittent closures, thereby affecting provision of onsite health care services, SBHCs should forge stronger connections with community providers. 8 This is especially important given the anticipated growing need of SBHCs to meet the physical and mental health 9 needs of students. Contingency plans should be made for students who have acute or subacute needs that are routinely managed in the school setting. One option to explore is allowing SBHCs to remain open, even if the school is closed. Additionally, SBHCs should re-emphasize the role of ongoing education and communication with parents about resources and consider creating a local resource list or referral mechanism for community providers.

THE ROLE OF TELEHEALTH
With the rapid expansion of telehealth services during COVID-19, some SBHCs have been able to implement telehealth options for health care, whereas others have been forced to shut down completely due to lack of resources or personnel. Although SBHCs have increased their telehealth capabilities over the past 10 years, more than 80% still lack resources to provide care remotely. 1 Now is the time for SBHCs to explore opportunities for building their telehealth capacity. This could have significant benefits for increasing access to health care in both urban and rural school communities. School districts have made notable strides in increasing Internet and device access for students during school closures, although a notable disparity in access to digital technology remains an ongoing challenge. SBHCs should take advantage of these online platforms, when available, to engage with families and offer remote health care access. One additional benefit of offering telehealth services is the option of having direct contact between the parent and provider, which will help strengthen understanding and compliance with treatment plans, as well as overall satisfaction in the family-provider partnership. 10 SBHCs also should learn from the experiences of community providers in how to optimize delivery of telehealth services and maintain student privacy.

Conclusions
SBHCs will be critical to school recovery during both the current and next academic year. They must reimagine their role in increasing access to care as new challenges arise amidst the COVID-19 pandemic. Strategies to improve parental communication and engagement, strengthen community provider partnerships, and expand telehealth capabilities should be considered to increase availability of school-based health services during a time when families arguably need it the most. To support their expanded role, health and education policymakers must recognize the integral role that SBHCs will play in supporting children's health and well-being and provide support through legislative and funding efforts. 11