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The second of four articles in the series During Pandemic, Rural Health Foundations Provide Financial Support, Technical Assistance, and Other Services
Overview of Claude Worthington Benedum Foundation's COVID-Related Activities
The Claude Worthington Benedum Foundation:

Paused its regular grant making to focus on immediate COVID relief and support existing safety net programs

Set up a grant capture team to mine and send out information concerning federal and other funding opportunities and funded grant writers

Convened with other health funders to determine who could fund activities in different areas of West Virginia, ensuring that each county was covered

Worked with the Partnership for African American Churches and the West Virginia Department of Health and Human Resources and funded three mobile units to complete COVID testing in communities of color

What is your foundation doing to support rural communities during the pandemic?
The Benedum Foundation is a regional foundation located in Pittsburgh. We serve four counties in Pennsylvania and we serve the state of West Virginia. Our health focus is across the state of West Virginia. Our priority areas for the last few years have been children's health and school readiness, improving the oral health infrastructure in the state, and preventive services and access to healthcare, which is really our response to the chronic diseases that are prevalent in the state.

We also fund some opportunity grants. Those are things that Benedum, being the largest funder in the state, sometimes must take on. People expect us to lead on issues that are difficult, and people expect us to have a leadership role in that. And so, sometimes we must step forward to help address something that comes up, like COVID. Historically, it would be supporting West Virginia VOAD (Voluntary Organizations Active in Disaster) to alleviate suffering from floods or other disasters. Because we built that infrastructure, it was in place for COVID, so we were able to use that for a public health disaster as we would have for a natural disaster.

West Virginia is the only state that's entirely in Appalachia, all 55 of our counties. The Benedum Foundation's health agenda is across the state. We traditionally work on policy, systems, and environmental changes, meaning we wouldn't usually fund one health department, but we'd want to think about how we can strengthen the entire infrastructure of health departments around the state.

So how could we do a system change for that? That's the approach that we took with COVID. I remember vividly: It was March, Friday the 13 th ― the last day that I was in public with people ― and it was with our group of West Virginia health funders. We were all together when the news broke that this was happening. So, we started meeting on a regular basis, and Benedum basically said, "Let's stop all of our regular planned grant making."

We looked at alleviating the social determinants of health and basic needs, which a lot of people did, such as food, PPE [personal protective equipment], shelter, economic supports, things like that. How do we hold up our childcare centers? Because if you had nowhere to safely care for your children, you couldn't go to work. And then we looked at system levels. How do we shore up our healthcare safety nets? One in five West Virginians get their healthcare at a Federally Qualified Health Center. A lot of people also use free clinics, and a lot of people use the local health departments.

We're able to call the state systems we fund, like the West Virginia Primary Care Association or the WV Association of Local Health Departments or the West Virginia Association of Free Clinics, and say, "What's the system change that we could help each of you with to shore up the immediate need?" And those folks were doing contact tracing. They were doing the drive-through clinics; they were testing people. They were getting supplies out to folks ― PPE and safety measures. The next phase was then: What's the federal opportunity that we can capture? And how do we help the organizations we fund be poised and ready?

A specific example is that Federally Qualified Health Centers weren't being reimbursed for telemedicine in all avenues before the pandemic, and so they weren't prepared to do telehealth. We really helped with infrastructure building across the West Virginia health funders, but Benedum took the lead in that because we wanted them to maximize their federal dollars. If they didn't have the infrastructure to do telehealth, they needed to purchase that and get that up and going so that they could then bill and serve their patients ― because they were going to serve them anyway, right? So we wanted to make sure that telehealth and tele-mental health, oral health, and medical interventions happened.

Who are the disenfranchised populations? Who are the people who are probably not being served the most? Once we shored up basic needs for everybody, we worked on: Are we truly reaching communities of color? Are we helping people who are homeless and shut-in seniors?

We also looked at: Who are the disenfranchised populations? Who are the people who are probably not being served the most? Once we shored up basic needs for everybody, we worked on: Are we truly reaching communities of color? Are we helping people who are homeless and shut-in seniors? Because seniors were a tough population ― because of the rural nature, they were more hesitant to let people come to their house, to even let them drop things off. A lot of them were not into Meals on Wheels because they were afraid that they could get the virus that way. And a lot of our Meals on Wheels volunteers were older, so we didn't have the drivers to drive that food. We really did some concerted effort of getting the protein-rich and diet-specific meals to seniors. We also worked with communities serving persons with substance use disorder because a lot of those folks were the first to lose jobs. In addition, persons who were homeless or at risk of homelessness were often the ones put out of facilities first or didn't have safety in a facility or the facility wasn't staffed.

We also supported outreach efforts. How do we do outreach in the right places? How do we work with the faith community to make sure that we're doing testing in those communities?
What other services would you like to highlight?
We did set up a grant capture team with a statewide intermediary. We funded an organization so that they could be mining all of the information that was coming out through the CARES Act and other opportunities, particularly federal, and then the dollars that came into the state. We funded people to mine the data, do short info pieces, and send them out to our statewide network systems like rural hospitals and the West Virginia Rural Health Association. We've funded them to do updates to their websites so there'd be current, accurate information about the virus or how to get tested, where to get PPE, and how to find funding. And we then funded the grant writers for people who needed them. We also serve as match for grants if people needed to match state or federal grants.

We reached out to all of our existing grantees and said, "If you need a no-cost extension, if you need a budget revision, if you need to reallocate your existing budget to have a COVID response, we will simplify all those processes and we will do those with emails, not within the online system." We tried to make things simpler for people. When the health funders started convening weekly in the beginning, we conducted mapping of where our geographic areas and our priority areas were. We created a map of the state and who could serve each county. There's only a few of us who can do statewide funding, so then we would parse out opportunities to collectively fund identified needs. If we wanted to fund a health department or free clinic infrastructure change or an intervention, then each foundation would take the ones in their region and we [Benedum] would take whatever was left, for example.

How do we now do system changes to get us back on track? Everything that was happening before COVID is still happening. We still have persons overdosing. We still have chronic disease. We still have children needing immunizations. So, we said, 'How do we keep those things from going off the rails?'

The last piece of the shift has been: How do we now do system changes to get us back on track? Everything that was happening before COVID is still happening. We still have persons overdosing. We still have chronic disease. We still have children needing immunizations. So, we said, "How do we keep those things from going off the rails?" An example is that we just funded a back on track program to get kids caught up on immunizations, with schools being intermittent or closed and kids being homeschooled. Children really have suffered with getting their immunizations. We're trying to get that caught up.

West Virginia is primarily a white state. We have a very low minority population. Even if you add up everyone who's not Caucasian, we're only at about an 8% rate of diversity, yet we were having a COVID infection rate of almost 24% in communities of color. We worked with the Partnership for African American Churches, which is a statewide organization, and the West Virginia Department of Health and Human Resources to do a COVID response for communities of color. And we've funded three mobile units to do testing with people whom they trust in communities where they trust them. We can improve testing, improve contact tracing, and then also get people flu shots, because there's a lot of distrust about immunizations in particularly the African American community in our state. There are people who still have relatives who were in the Tuskegee experiment. So, we partnered and helped leverage $1.4 million with the state government to provide this program with the Partnership for African American Churches.

We funded $4 million with 38 direct COVID grants. And we funded about 13 other COVID-impacted areas, such as: How do we bring arts communities back online? How do we help build stages for more interventions to happen outside, whether they're a health intervention or a community event or an arts event? We also helped farmers markets so that we continue to have fresh fruits and vegetables.

And the one population that we did also specifically reach out to is grand families, kinship families, and foster parents, because we have one of the highest percent of children per capita living in foster care, mostly because of the substance use disorder crisis we've had. Those families really struggled with getting their children's healthcare needs met, so we really did concerted efforts of outreach to them.

If you don't have food, clothing, shelter ― Maslow's hierarchy ― then you can't go to work, you can't focus, and you can't have a strong community. The whole work infrastructure has been so interrupted and, in a state where we struggle with broadband, it's been really difficult for our families because people are driving to fast food restaurants to have a hotspot to do homework and they're doing shifts and then they're trying to work from home. There's a bunch of people, a preponderance of people, who don't have access to broadband.

We don't give grants and walk away ― We give you a grant and we move in with you. We roll our sleeves up and work each day.

And then how do we plan for the future? We've got to figure out how to provide COVID immunizations across the state. How do we get that vaccine out to the public? How do we educate folks? Benedum is not a typical kind of foundation. We don't give grants and walk away ― We give you a grant and we move in with you. We roll our sleeves up and work each day. We're on the state response teams; I'm getting daily briefings from the governor's office so that we know how we can make that system change.
What else would you like to share?
I was proud of the collaborative effort we did with the West Virginia health funders, getting those organizations to work together, because we all have different boards. We all have different priorities, different giving areas, but I feel proud that we were able to redirect $4 million. We do this partnering work all the time, but we really dug our heels in. We would get proposals and we would pitch them to one another and say, "Here's what this need is. We can cover this, but we can't cover that." And our boards were very responsive to provide a state response.

Childcare centers had to throw out all their toys and had to get all the cleaning products. We had folks going to the dollar store every day trying to get cleaning products. Well, that's not a good use of your time. So, we funded case management. There's a national VOAD and every state has one and they are mobilized to feed people and keep you safe. And that's where we manage PPE. Every week or so, I get an email from VOAD that says, "Hey, we just got resources from FEMA. Which clinics need N95 masks right now?" And we were able to deploy those items. Investing in the infrastructure of core intermediary organizations so they can be nimble and organized when something bad happens really has paid off for our state.

That's the joy and the beauty of rural America: We really do know how to help and care for one another. Those relationships make things happen when we have times of need.

That's the joy and the beauty of rural America: We really do know how to help and care for one another. Those relationships make things happen when we have times of need.

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Claude Worthington Benedum Foundation: Taking a Leadership Role and Building Trust - The Rural Monitor

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Kim Barber Tieman, program director for health and human services for the Claude Worthington Benedum Foundation, shares how her foundation set up a COVID-19 grant capture team and funded grant writers to help organizations navigate and apply for federal funding opportunities.

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Telehealth has the potential to offer many children and families a lifeline to essential physical and behavioral health services that would not otherwise be accessible. Although the use of telehealth in child welfare practice has been of interest for many years, particularly in rural areas, more jurisdictions are now expanding its use to support child and family access to critical services during the present COVID-19 crisis - with the potential to carry it forward beyond the pandemic. Telehealth has the potential to:

Increase access to specialized medical and mental health expertise.

Ameliorate client transportation and time barriers.

Enhance staff capacity by reducing travel time in remote areas.

Increase acceptance of services by some clients who may be more comfortable participating remotely.

Realize cost savings that may help to offset anticipated post-pandemic budget shortfalls.

More child welfare-specific research is needed, but studies comparing the outcomes of in-person and telehealth for physical and behavioral health care services have generally found that the two approaches can achieve similar results. This strategy brief discusses a variety of uses for telehealth in the child welfare context, provides some key implementation considerations, and offers examples of use in specific jurisdictions. For additional resources, see: Where can child protection leaders learn more about implementing telehealth for behavioral health services?

Telehealth in child welfare

According to the U.S. Substance Abuse and Mental Health Services Administration, telehealth services often are provided in real time through videoconferencing, chat, and text messaging. Telehealth also includes services provided through email, online training, automated computer programs, and mobile apps, or through a client video recording that a professional reviews remotely at another time.

Some examples of how telehealth can be used to support children and families involved with the child welfare system include:

Using telemedicine technology to conduct remote medical examinations for suspected child abuse and neglect. This approach can make investigations more accurate and timely, and less burdensome for families, when there is no child abuse pediatrician practicing in the area.¹

Providing "virtual home visits." Most of the national early childhood home visiting models have endorsed the use of videoconferencing and other technologies during the COVID-19 crisis and provided related guidance.

Facilitating completion of service plans by offering remote access to some required services, such as parent education, support groups, and substance use disorder treatment.²

Key considerations

Some questions to consider for child protection agencies implementing telehealth services are: ³

How will client safety and confidentiality be protected? During the pandemic, the U.S. Department of Health and Human Services' Office for Civil Rights announced that health care providers would not be subject to penalties for violations of HIPAA (Health Insurance Portability and Accountability Act) privacy rules that occurred during the good faith provision of telehealth. This opened up opportunities for services to be delivered on a wider variety of non-HIPAA-compliant platforms, including FaceTime, Zoom, and Skype. Privacy and confidentiality are still important considerations, however, bringing forth a range of key questions: How will consent forms be updated to reflect telehealth, and how will client signatures or acknowledgements be obtained? What protocols will be necessary to ensure client privacy at both the provider's location (e.g.,soundproof work spaces, headphones) and the client's (e.g., asking who is present, taking care not to bring up sensitive topics if it is unclear whether the client is alone)?

How will the agency adhere to evidence-based practices? Research suggests that some evidence-based practices (for example, Cognitive-Behavioral Therapy and Trauma-Focused Cognitive-Behavioral Therapy) can be delivered effectively using virtual communication.⁴ The implementation and effectiveness of telehealth, however, will likely vary by model. It is important to review research and/or consult with model developers whenever possible. Tracking outcomes of telehealth approaches is important and will continue to build the body of evidence in this emerging area of child welfare practice.

Jurisdictional examples

In Colorado, Invest in Kids is a state-based intermediary for a home visiting model, Nurse-Family Partnership (NFP), and a social and emotional program, Incredible Years (IY). Prior to the COVID-19 crisis, NFP used virtual communication to connect staff across the state, support reflective supervision, and conduct home visits with established clients under specific circumstances (such as inclement weather or a client's move out of state). In part due to this established foundation, NFP was able to pivot to almost exclusively virtual home visitation quickly after the onset of the pandemic by working closely with model developers and national service offices, expanding on protocols already in place (for HIPAA compliance and client consent), and offering staff training in effective virtual communication techniques. IY staff also have been able to continue established parent groups and support classroom-based social skills lessons via Zoom. All telehealth services have been well received - in fact, NFP enrollment was higher in March 2020 than March 2019 (when introductory meetings were conducted exclusively in person). Invest in Kids is now gathering data that will allow comparison of model fidelity and outcomes for in-person and telehealth services on a variety of measures.

As an urban county with ready access to behavioral health expertise, a breadth of services, and an investment in face-to-face care, Allegheny County has been thoughtful about its approach to implementing telehealth. When the COVID crisis hit, the Office of Behavioral Health had just opened the option of telepsychiatry to address an emerging shortage of psychiatrists. With the onset of the pandemic, previously strict state regulations were relaxed, and providers were encouraged to quickly ramp up additional mental health and substance abuse treatment services via telehealth. Close partnership with provider agencies has been essential, leaders note, and has paid off in a wealth of creative solutions including: immediate access to psychiatrists in hospital emergency rooms and juvenile detention facilities; virtual access to certified recovery specialists; and telehealth monitoring coupled with mobile delivery of medication assisted treatment for opioid addiction. With more ways to engage clients, substance use disorder treatment providers are optimistic that they may see more engagement and longer lengths of stay in outpatient treatment, which are two key indicators for positive outcomes. The county is also hearing anecdotal reports from providers regarding increased staff morale, productivity, and engagement.

In 1998, Florida became the first state to pilot the use of telehealth for expert medical evaluations of child maltreatment allegations. The program currently operates in 17 sites through a hub-and-spoke system that connects specialized child abuse pediatricians in urban areas to surrounding counties where that expertise is lacking. On-site nurses use advanced image capture and other telemedicine equipment to assist the remote doctors in conducting approximately 500 examinations per year. An early evaluation found that families' concerns about the technology were easily resolved, and that the technology seemed to increase timeliness of decision-making while reducing stress and inconvenience for the child and family. ⁵

1 Arnold, S. & Esernio-Jenssen, D. (2013). Telemedicine: Reducing trauma in evaluating abuse. Retrieved from https://www.intechopen.com/books/telemedicine/telemedicine-reducing-trauma-in-evaluating-abuse.
2 See, for example: Taylor, T.K., Webster-Stratton, C., Feil, E. G., Broadbent, B., Widdop, C. S., & Severson, H. H. (2008). Computer-based intervention with coaching: An example using the Incredible Years Program. Cognitive Behaviour Therapy, 37, 233-246. Retrieved from https://www.tandfonline.com/doi/abs/10.1080/16506070802364511; Reese, R. J., Slone, N. C., Soares, N., & Sprang, R. (2015). Using telepsychology to provide a group parenting program: A preliminary evaluation of effectiveness. Psychological Services, 12(3). 274-282. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25602503; Schamberger, K. (2016, October 27). Addiction treatment organization finds success with online program. KC Digital Drive. Retrieved from https://www.kcdigitaldrive.org/article/addiction-treatment-organization-finds-success-with-online-program/.
3 Information in this brief is based in part on interviews with Denise Macerelli, Jewel Denne, and Dr. Latika Davis-Jones, Allegheny County Department of Human Services' Office of Behavioral Health; Dennis Watson, Florida Department of Health; and Lisa Hill, Julie Steffen, and Michelle Neal, Invest in Kids.
4 Dent, L., Peters, A., Kerr, P. L., Mochari-Greenberger, H., & Pande, R. L. (2018). Using telehealth to implement cognitive-behavioral therapy. Psychiatric Services. Retrieved from https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201700477; Stewart, R. W., Orengo-Aguayo, R. E., Cohen, J. A., Mannarino, A. P., & de Arellano, M. A. (2017). A pilot study of trauma-focused cognitive-behavioral therapy delivered via telehealth technology. Child Maltreatment, 22(4), 324-333.
5 Pammer, W., et al. (2001). Use of telehealth technology to extend child protection team services. Pediatrics, 108, 584-90.

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Telehealth & Child Welfare - Casey Family Programs

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Telehealth has the potential to offer many children and families a lifeline to essential physical and behavioral health services that would not otherwise be accessible.