Develop a North Carolina Framework for Health
Create a vision and a framework to build a culture of health in the state. A coordinated plan could help ensure that all children, families and individuals have the opportunity to:
- Be born healthy
- Grow up healthy
- Live in healthy and safe communities
- Pass on opportunities for good health to their children1
National organizations have created health frameworks that North Carolina can learn from. These examples focus on prevention and early childhood, and they highlight the importance of social determinants of health and health equity.
- National Scientific Council on the Developing Child
- Healthy People 2020
- Robert Wood Johnson Foundation:
- Commission to Build a Healthier America
- Pathways to Health Equity
- Building a Culture of Health
North Carolina could convene diverse stakeholders to review and coordinate policies, practices, programs and actions steps using a combination of elements from these national frameworks.
- Robert Wood Johnson Foundation. (2014). Time to Act: Investing in the Health of Our Children and Communities. Retrieved from http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf409002#page=62 ↵
Provide Health Insurance
Maintain the current high rate of insured children and increase health insurance coverage rates for parents.
Children with health insurance are more likely than uninsured children to have:
- Regular preventive health care and other needed services
- A medical home
- Fewer emergency room visits
- Their health care needs met1
When parents have health insurance, their children are more likely to be covered and are more likely to access needed health services.2
Most children in North Carolina have health insurance.3 In 2015, 96 percent of children in the state were insured, with more than 40 percent of children insured through Medicaid and Health Choice.
North Carolina parents are less likely to be insured than their children. In 2015, 20 percent of North Carolina children lived with a parent who was not covered by any health insurance. In addition, nearly a quarter of insured adults do not have enough coverage or cannot make use of the insurance due to high co-pays and deductibles.4
North Carolina’s public child and family health insurance coverage currently includes:
- Coverage for children living in households with incomes up to 211 percent of the Federal Poverty Level (FPL), through Medicaid or Health Choice (North Carolina’s Children’s Health Insurance Program, or CHIP)
- Maternity coverage for pregnant women with household incomes up to 196 percent of FPL
- Coverage for parents with dependent children with a household income of up to 45 percent of FPL
- Coverage for family planning (the Be Smart program) for those with incomes up to 195 percent of FPL5
- Zero to Three. (2009). Early Experiences Matter: A Guide to Improved Policies for Infants and Toddlers. Retrieved from http://main.zerotothree.org/site/DocServer/Policy_Guide.pdf?docID=8401 and Child Trends. (2013). The Research Base for a Birth through Eight State Policy Framework. Retrieved from http://www.childtrends.org/wp-content/uploads/2013/10/2013-42AllianceBirthto81.pdf ↵
- George Washington University School of Health Policy and Health Services. (2007). Parental Health Insurance Coverage as Child Health Policy: Evidence from the Literature. Retrieved from: http://publichealth.gwu.edu/departments/healthpolicy/CHPR/downloads/Parental_Health_Insurance_Report.pdf ↵
- KidsCount Data Center, Annie E Casey Foundation, Children who have a parent with no health insurance. Retrieved July 14, 2017 from http://datacenter.kidscount.org/data#NC ↵
- Commonwealth Fund. (2014). Biennial Health Insurance Survey. Retrieved July 14, 2017 from http://www.commonwealthfund.org/publications/issue-briefs/2015/may/problem-of-underinsurance ↵
- North Carolina Medicaid, Health Insurance.Org, undated. Retrieved January 22, 2017 https://www.healthinsurance.org/north-carolina-medicaid/ ↵
Conduct Health Equity Impact Assessments
Require agencies involved in local strategic planning for transportation, land use and housing development to work with public health agencies to identify potential health equity consequences of proposed actions.
Health equity means that everyone has a fair opportunity to be healthier, with access to things like good jobs, high quality education, housing, safe environments, and health care.1
Regional planning efforts for basic infrastructure like roads, industrial and residential zoning, and green spaces can either promote or be a detriment to community health.2 Examples of strategies used to address this issue include:
- Formal partnerships between community planning departments and their public health agency
- Regional coordination among several county public health departments and city and rural planners
- Urban partnerships between state health departments and metropolitan area planning councils3
- Robert Wood Johnson Foundation, “What is Health Equity,” May 2017. Retrieved February 2018 from https://www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.html ↵
- Rubin, V. (2015). Regional Planning for Health Equity. Retrieved March 31, 2017 from http://www.policylink.org/sites/default/files/Regional-Planning-for-Health-Equity_FINAL.pdf ↵
- Rubin, V. Regional Planning for Health Equity, op cit. ↵
Address Social Determinants of Health
Non-medical factors that affect health are often called social determinants of health. They include factors like whether someone has a good education, a job, access to adult education, stable finances, and access to healthy food, social supports, transportation and safe housing. The zip code that someone lives in can be a strong predictor of how healthy she will be or how long he will live.1
North Carolina can:
- Incorporate non-medical factors into community health assessments
- Report on non-medical factors as part of health benchmarking
- Incentivize health care providers through the reimbursement process to address non-medical factors that affect health
Public spending may be one factor in health outcomes. Counties with better health care outcomes2 spend larger proportions of their budgets on social determinants of health like parks and recreation, sewers, fire protection, and libraries. These investments improve people’s health, even though that may not be their primary purpose.3
- Robert Wood Johnson Foundation, Time to Act, op cit. ↵
- McCullough, J.M. & Leider, J.P. (2016). Government Spending in Health and Nonhealth Sectors Associated with Improvement in County Health Rankings. Health Affairs, 35(11), 2037-2043. Retrieved from http://content.healthaffairs.org/content/35/11/2037.full?ijkey=h25LrWseHQgsw&keytype=ref&siteid=healthaff ↵
- McCullough & Leider, Government Spending in Health and Nonhealth Sectors, op cit. ↵
Ensure Effective Formal Supports for Low-Income Families
Maintain and strengthen a set of proven policies known to support the health and well-being of low-income families. Examples include:
- Refundable tax credits for working families
- Pregnancy and parenting benefits, including family leave
- Health insurance, including Medicaid
- Adult mental health screening and treatment, including for maternal depression and Adverse Childhood Experiences (ACEs)
- Full enrollment in public benefit programs
- Housing supports
- Access to high quality child care for working parents
- Nutrition programs like WIC and SNAP
Support Family Knowledge, Skill and Engagement in their Children’s Health
Provide family-friendly written resources or technology-based applications that help caregivers better understand their children’s health progress and needs, learn what is recommended, and find resources to address their children’s health needs. Provide information and the impact of Adverse Childhood Experiences (ACEs) on children’s health and development.
There are many resources that could be used to support parents’ understanding of their children’s health. Examples include:
- American Academy of Pediatrics Bright Futures for Well-Child Care guidelines and materials. They include handouts for each well-child visit1, a Well-Child Visit Planner available online and as a mobile phone app2, a Child Health Tracker3, a Systems Checker4 (an interactive online screen that uses a scroll-over interactive screen based on a child’s body), and an ADHD Tracker.5
- Ages & Stages developmental tracking tool. It is increasingly being made available to parents through public libraries, Early Head Start and Head Start programs, and local public health offices. When parents complete these questionnaires about their children’s development, alone or with assistance, results are provided along with recommendations to support children’s development and/or referrals for help and interventions.6
Reach Out and Read at well child visits. Pediatricians encourage parents to read to their children, model shared book reading, and provide each child with a new book appropriate to his or her age. This evidence-based model could be leveraged and expanded to include health-related materials and education for parents as well.7
- American Academy for Pediatrics. (n.d.). Bright Futures: Resources for Families. Retrieved March 13, 2017 from https://brightfutures.aap.org/families/Pages/Resources-for-Families.aspx ↵
- The Child and Adolescent Health Measurement Initiative and Oregon Health and Science University (n.d.). Well-Child Visit Planner. Retrieved March 13, 2017 from http://www.wellvisitplanner.org/ ↵
- American Academy of Pediatrics. (2013). Child Health Tracker. Retrieved from https://itunes.apple.com/us/app/child-health-tracker-from/id664576969?ls=1&mt=8 ↵
- American Academy of Pediatrics. (n.d.). KidsDoc Symptom Checker. (n.d.). Retrieved March 13, 2017 from https://www.healthychildren.org/english/tips-tools/symptom-checker/Pages/default.aspx ↵
- American Academy of Pediatrics. (2012). ADHD Tracker. Retrieved March 13, 2017 from https://itunes.apple.com/us/app/adhd-tracker-1.0/id553571938?ls=1&mt=8 ↵
- Connecticut 2-1-1 Child Development Infoline. (2017). Ages and Stages. Retrieved March 22, 2017 from http://cdi.211ct.org/program/ages-and-stages/. Easter Seals of Pennsylvania. (2017). Make the First Five Count. Retrieved from http://www.easterseals.com/mtffc/?referrer=http://es.easterseals.com/site/PageNavigator/ntlc10_mffc_homepageasq.html. Healthy Child Care Pennsylvania Early Childhood Education Linkage System. (n.d.). ASQ Developmental Screening Free Online Tool. Retrieved March 22, 2017 from http://www.ecels-healthychildcarepa.org/publications/health-capsules/item/339-asq-developmental-screening-free-online-tool ↵
- Reach Out and Read. (n.d.). About Us: Mission and Model. Retrieved from http://www.reachoutandread.org/about-us/mission-and-model/ ↵
Screen All Children and New Mothers
Screen all children regularly for common childhood delays and health issues, and screen new mothers for maternal depression. Screening areas include:
- Developmental Delays. Review developmental screening rates, disaggregated by county and race/ethnicity. Use data to inform strategic investment in North Carolina’s ABCD developmental screening program, in order to reach all Medicaid-eligible children participating in well-child visits.
ABCD is a national developmental screening, prevention, and early intervention program model now operating in 27 states. It is led by the National Academy for State Health Policy and supported by The Commonwealth Fund.1 ABCD began in North Carolina in 2000. In North Carolina, ABCD includes all 14 Community Care of North Carolina (CCNC) networks.2 In 2013, 40 North Carolina pediatric practices with a total of 239 medical providers participated in ABCD. Across these practices, just over 36,000 children were served; 57 percent of these children were covered by Medicaid.3 North Carolina has been recognized for leading the nation in EPSDT services, with a rate of developmental screening at well-visits of 84 percent.4
- Need for Early Intervention. Widen eligibility for Early Intervention services to include children at risk for disability based on family non-medical factors. In North Carolina, eligibility for Early Intervention is currently limited to certain levels of developmental delay and/or certain established medical conditions like a genetic disorder, autism, hearing or vision impairment, or other. North Carolina could learn from other states that have adopted Early Intervention eligibility criteria that include at-risk circumstances like poverty, homelessness, substance abuse or mental illness in the home.5
- Hearing and Vision Problems. Ensure universal use of American Academy of Pediatrics and North Carolina Department of Health and Human Services6 protocols. The goal of universal hearing screening is detection of hearing loss in infants before three months of age and providing appropriate intervention by no later than six months of age. This practice is recommended both by the American Academy of Pediatrics and the North Carolina Department of Health and Human Services. The American Academy of Pediatrics recommends vision screening beginning at age three or four.
- Lead Exposure. Screen children regularly for lead exposure, particularly children from communities with environmental risk factors. These factors include aging housing painted with lead paint, municipal water transmitted through lead pipes or from contaminated aquafers, and soil contaminated with lead.7
Although Medicaid pays for lead screening through its Early Periodic Screening, Diagnosis and Treatment (EPSDT) program, a recent national study found that only four in ten Medicaid-enrolled infants and toddlers had been tested.
The North Carolina Division of Public Health recommends universal blood lead testing at certain well-child visits. All North Carolina children enrolled in Medicaid, Health Choice and WIC, as well as refugee children, are required to receive blood lead screening.8 North Carolina’s Childhood Lead Poisoning Prevention Program coordinates childhood lead poisoning reduction efforts through early identification, surveillance, risk assessments, abatement, and monitoring.9 A coordinated approach to universal lead screening is required by local North Carolina Health Departments including all local primary care providers.10 However, federal grant funds have been reduced or have ended11 and local health departments continue to face funding challenges.12
- Maternal Depression. Ensure that women are being screened for prenatal and post-partum depression, as directed under a 2016 Medicaid administrative policy.
Maternal depression following the birth of a child can negatively impact parent-child interactions and babies’ and young children’s early development.13 Among low-income women living with chronic stress, as many half experience clinically-diagnosable depression.14
In North Carolina, women receive maternal depression screenings through a few systems:
- The Pregnancy Medical Home initiative provides prenatal and postpartum depression screenings that must be covered by insurers at no cost to patients.15 The screening process also helps parents understand the processes of early child development.16
- The North Carolina Health Check Program identifies mothers that may be at risk for depression in the child’s first year and refers them to services as appropriate.17
- In July 2016, North Carolina Medicaid began to reimburse providers for up to four maternal depression screenings of a new mother during her infant’s first year.18
- The Commonwealth Fund. (n.d.). Archived: State Health Policy and Practices. Retrieved from http://www.commonwealthfund.org/grants-and-fellowships/programs/archived-programs/state-health-policy-and-practices ↵
- Community Care of North Carolina. (n.d.). Assuring Better Child Health and Development. Retrieved November 8, 2016 from https://www.communitycarenc.org/population-management/medical-home/ABCD/ ↵
- Smart Start. (n.d.). Advancing Child Health. Retrieved January 28, 2017 from http://www.smartstart.org/advancing-child-health/ ↵
- Zero to Three. (2016). North Carolina Medicaid requires developmental screening in health settings. Retrieved from https://www.zerotothree.org/resources/863-north-carolina-medicaid-requires-developmental-screening-in-health-settings ↵
- The Early Childhood Technical Assistance Center, States’ and territories’ definitions, op cit. and Massachusetts Legal Services, Children’s Issues Series: Early Intervention. Retrieved February 2018 from https://www.masslegalservices.org/system/files/library/Children%20seriesEarly%20Intervention%20QA_031212.pdf ↵
- North Carolina Department of Health and Human Services. (2014). Why Do Newborns and Young Children Need Hearing Screening? Retrieved from http://www.ncnewbornhearing.org/files/OutreachArticle-PA-EditsBorderTagline-42414.pdf ↵
- Schneyer, J. & Pell, M.B. (2016). Unsafe at Any Level: Millions of American children missing early lead tests. Retrieved from http://www.reuters.com/investigates/special-report/lead-poisoning-testing-gaps/ ↵
- North Carolina Department of Health and Human Services, North Carolina Lead Testing and Follow Up Manual, op cit., p 6 ↵
- North Carolina Health and Human Services. (n.d.). Children’s Environmental Health. Retrieved February 14, 2017 from http://ehs.ncpublichealth.com/hhccehb/cehu/index.htm ↵
- North Carolina Department of Health and Human Services, North Carolina Lead Testing and Follow Up Manual, op cit., p. 6 ↵
- Centers for Disease Control and Prevention. (2017). Lead, North Carolina. Retrieved from https://www.cdc.gov/nceh/lead/programs/nc.htm ↵
- North Carolina Health News, Lead Poisoning Remains a Problem Even as Incidence Drops, op cit ↵
- Schmit, S., Golden, O., & Beardslee, W. (2014). Maternal Depression: Why It Matters to an Anti-Poverty Agenda for Parents and Children. Retrieved from http://www.clasp.org/resources-and-publications/publication-1/Maternal-Depression-and-Poverty-Brief-1.pdf ↵
- Schmit et al, Maternal Depression: Why It Matters to an Anti-Poverty Agenda for Parents and Children, op cit. ↵
- North Carolina Institute of Medicine. (2012). Prevention. In Growing Up Well: Supporting Young Children’s Social-Emotional Development and Mental Health in North Carolina (Chapter 14, p. 70-71). Retrieved from http://www.nciom.org/wp-content/uploads/2012/08/Chapter-41.pdf ↵
- Zero to Three, North Carolina Medicaid requires, op cit. ↵
- North Carolina Department of Health and Human Services, N.C. Health Check Program Guide, op cit. ↵
- “CMS directs use of CPT code 99420 (Health Risk Screen), one (1) unit per administration, with EP modifier when billing for this service. When conducted as part of a comprehensive Health Check Early Periodic Screening visit, this screen may be billed to the infant’s Medicaid coverage. Providers should carefully review this Program Guide’s section on General Guidance on Use of Structured Screening Tools and follow all documentation requirements.” NC Department of Health and Human Services, NC Health Check Program Guide, op cit., p. 43 ↵
Ensure Access to Effective Treatment
Screening is a critical first step to ensuring health. Referral to services and access to high quality services is also essential. North Carolina can craft legislative, administrative and/or financial supports for treatment of chronic health conditions (oral health, asthma, malnutrition and obesity, and lead exposure) among North Carolina’s younger children. A few treatment areas are highlight below.
- Maternal Depression. Conduct quarterly reviews of state and county administrative data to ensure that mothers with depression obtain access to timely, evidence-based treatment. Identify racial/ethnic and geographic disparities in treatment access and address gaps.
Cognitive Behavior Therapy (CBT) is a type of mental health treatment with strong evidence of effectiveness in helping individuals to change how they act, feel, think, and deal with problems. Hundreds of studies have shown CBT to be effective for substance use and smoking disorders, depression and anxiety, and post-traumatic stress disorders. CBT therapists focus on the current situation and its solution over a multi-session period.1 Moving Beyond Depression is a CBT-based program that works with two-generation home visiting programs to provide clinical maternal depression treatment.2
- Tooth Decay. Use data from the North Carolina Into the Mouths of Babes program to determine where gaps exist in access to treatment of tooth decay in young children, and the reasons for those gaps. Consider expanding the North Carolina Dental Home program, in which dentists and pediatricians work together to provide dental care to young children, to address these gaps.3 Having regular oral screening visits reduces both dental office visits and hospitalizations for cavities.4
- Asthma. Link student absence data from Local Education Agencies (LEAs) with administrative data on Medicaid-enrolled children to identify trends in the prevalence of asthma by population group and geography. Prepare annual reports as part of the North Carolina Asthma Plan.
- Reduce asthma-related health disparities
- Improve asthma care service delivery
- Decrease asthma-related early education and K-12 school absences
- Increase community involvement and environmental awareness8
The North Carolina Department of Health and Human Services provides training in managing asthma for school nurses and other elementary and middle school staff, coaches, parents, and child care providers.9
- Malnutrition and Obesity Treatment. As part of the North Carolina Shape NC program, track and report on the changes in how many young children are overweight or obese. Where data show a high rate of obesity or an increase in obesity, work with parents, pediatricians, early childhood and public health programs to address factors contributing to these trends.
Mothers’ malnutrition during pregnancy can undermine babies’ growth in the womb as well as children’s health and development after birth and over time.10 Malnutrition in young children negatively impacts both health and learning.11 Nearly one in three of the state’s children are overweight or obese, and significant health disparities exist in obesity prevalence.12 Malnutrition in children can result in under- or overweight.
Shape NC: Healthy Starts for Young Children is a multi-year initiative that works with child care providers to increase the number of the state’s children who enter school at a healthy weight. Sponsored by the Blue Cross and Blue Shield of North Carolina Foundation, Smart Start and the North Carolina Partnership for Children, Phase I of this initiative engaged with communities in 27 of the state’s 100 counties to reach over 1,000 young children. Phase II expanded the program to 213 child care centers reaching over 10,000 children.13 Phase I results are promising, as centers nearly doubled the number of best practices adopted, with significant increases in active play, decreases in screen time, and increases in healthy food offered two or more times a day and outdoor play. Evaluation reveals that the percent of children with healthy weight has been gradually increasing.14 Federal and private funds will continue and expand the work.15
- Hofmann, S. G., Asnaani, A., & Fang, A. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive Therapy and Research, 36(5), 427-440. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584580/ ↵
- Johnson K., Ammerman, R.T., & Van Ginkel, J.B. (2014). Moving Beyond Depression. An Effective Program to Treat Maternal Depression in Home Visiting: Opportunities for States. Retrieved from http://fhop.ucsf.edu/sites/fhop.ucsf.edu/files/custom_download/MBD%20white%20paper.pdf ↵
- NC Department of Health and Human Services. (n.d). Carolina Dental Home Program. Retrieved March 9, 2017 from https://www2.ncdhhs.gov/dph/oralhealth/partners/CarolinaDentalHome.htm ↵
- NC Department of Health and Human Services, Into the Mouths of Babes, op cit. ↵
- North Carolina Department of Health and Human Services, Chronic Disease and Injury Section. (2017). North Carolina Asthma Plan (2013-2018). Retrieved from http://www.asthma.ncdhhs.gov/docs/NorthCarolinaAsthmaPlan-2013-2018.pdf ↵
- Asthma and Allergy Foundation of America, Asthma Facts and Figures: Research, op cit. ↵
- North Carolina Department of Health and Human Services, North Carolina Asthma Plan, op cit. ↵
- North Carolina Department of Health and Human Services, North Carolina Asthma Plan, op cit., p. 10 ↵
- North Carolina Department of Health and Human Services. (n.d.). Asthma Program Initiatives. Retrieved March 26, 2017 from http://www.asthma.ncdhhs.gov/initiatives.htm ↵
- Slayton, R. (2015). Malnutrition in Pregnancy. Retrieved March 15, 2017 from http://www.livestrong.com/article/492523-malnutrition-in-pregnancy/ ↵
- Chulack, A. (2016, 11 September). The Importance of Nutrition in Early Childhood Development. Retrieved March 15, 2017 from https://novakdjokovicfoundation.org/importance-nutrition-early-childhood-development/ ↵
- Alliance for a Healthier Generation. (n.d.). North Carolina. Retrieved March 26, 2017 from https://www.healthiergeneration.org/about_childhood_obesity/in_your_state/north_carolina/ ↵
- Smart Start. (n.d.). What is Shape NC? Retrieved from http://www.smartstart.org/shape-nc-home/ ↵
- Smart Start. (2017). Shape NC Results. Retrieved from http://www.smartstart.org/shape-nc-home/shape-nc-results/ ↵
- Smart Start. (2016, 16 August). Smart Start Receives New Federal Grant to Fight Early Childhood Obesity. Retrieved from http://www.smartstart.org/smart-start-receives-new-federal-grant-to-fight-early-childhood-obesity/ ↵
Provide School-Based Health Interventions
North Carolina can deliver health services to children while they are in school. Areas of school-based health intervention include:
- School-Based Telehealth Programs. Scale North Carolina’s rural school-based telehealth program, which has been identified as a national model.
School-based telehealth services have been shown to be effective in the treatment of chronic health conditions, such as asthma and ADHD; improve coordination among parents, schools and health care providers; reduce school absences; offer greater satisfaction with health education; and be cost effective.1
School-based telehealth services in North Carolina were piloted in three rural schools and had expanded to 33 schools in four counties as of 2017. My HealtheSchools is now recognized as a national model.2 The service uses videoconferencing and other technology to allow centrally-located health care providers to examine students at multiple schools without traveling. Common and chronic health problems can be addressed (e.g., ear or stomach aches, and medication management) as well as well-child checkups and sports physicals. With parental permission, any student may use the service, with payment covered by both public and private insurance companies.3
- Recess and Physical Activity. Ensure access to and reporting on recess, physical activity and physical education across North Carolina’s birth through third grade continuum.
During the early elementary school years, recess provides the opportunity and context for cognitive and emotional development, the development of social skills, and the advancement of physical health and skills. It is especially important given the rising numbers of young children who are overweight or obese. Formal physical education is a complement to recess, not a substitute for it.4
America’s K-12 educational system is currently experiencing an increase in hours spent in large group, teacher-lead learning, with a reduction in time for physical activity and recess.5 In North Carolina, state education policy requires that, in addition to physical education, schools schedule at least 30 minutes of recess for K-8 students each day, which cannot be denied as a form of punishment.6
- School Nurses and School Health Clinics. Increase the number of school health clinics in K-8 schools and increase the number of school nurses to achieve nationally recommended nurse to student ratios.
The American Academy of Pediatrics recently recommended that every school in the nation employ at least one full-time nurse7 to address student health needs, ensure a strong connection with each student’s medical home, conduct emergency preparedness, and provide ongoing health education.8 The presence of school nurses has been shown to reduce student absenteeism and address other health problems such as asthma and obesity.9 School health clinics have been associated with improved access to care, prevention of diabetes and management of asthma, promotion of positive oral, behavioral and reproductive health, improved student attendance and behavior, reduction in dropouts, and improved school climate.10
North Carolina employs more than 1,200 registered nurses who each serve an average of 1,112 students, across the state’s 115 school districts.11 That means each nurse sees nearly 50 percent more students than the federal recommendation of one nurse for every 750 students.
As of 2017, there were 20 school-based health clinics in North Carolina elementary schools, with one additional program offering dental-only services. There were 23 elementary school-based telehealth programs.
- Reynolds, C. & Maughan, E. (2014). Telehealth in the School Setting: An Integrative Review. The School Health Journal. Retrieved from http://journals.sagepub.com/doi/full/10.1177/1059840514540534 ↵
- Raths, D. (2017, February 1). N.C. School-Based Telehealth Program Grows Into National Model. Healthcare Infomatics. Retrieved April 7, 2017 from https://www.healthcare-informatics.com/article/telemedicine/nc-school-based-telehealth-program-grows-national-model ↵
- HealtheSchools. (n.d.). Retrieved April 7, 2017 from http://crhi.org/MY-Health-e-Schools/index.html ↵
- American Academy of Pediatrics, The Crucial Role of Recess in School, op cit. ↵
- American Academy of Pediatrics, The Crucial Role of Recess in School, op cit. ↵
- Education Commission of the States, Recess Policies, op cit. ↵
- American Academy of Pediatrics. (2016). AAP Policy Statement Recommends Full Time Nurse in Every School. Retrieved from https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/AAP-Policy-Statement-Recommends-Full-Time-Nurse-in-Every-School.aspx ↵
- American Academy of Pediatrics. (2016). Role of the School Nurse in Providing School Health Services. Retrieved from http://pediatrics.aappublications.org/content/early/2016/05/19/peds.2016-0852 ↵
- Michael, S., Merlo, C., Basch, C. Wentzel, K. & Wechsler, H. (2015). Critical Connections: Health and Academics. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/josh.12309/full ↵
- California School-Based Health Alliance. (2015). School-Based Health Centers: Proven Results. Retrieved from https://www.schoolhealthcenters.org/wp-content/uploads/2015/01/CSHA-SBHC-Proven-Results-2014.pdf ↵
- NC Department of Health and Human Services. (n.d.). About Us: School Nurses. Retrieved February 14, 2017 https://www2.ncdhhs.gov/dph/wch/aboutus/schoolnurses.htm ↵