The only hospital in rural Pickens County, Ala., closed its doors for good just two weeks before the COVID-19 pandemic hit.
It was March 2020. The west Alabama county sits along the Mississippi state line, its landscape dotted with small towns. When the hospital closed in the county seat of Carrollton (pop. 1,000), Pickens County lost four physicians, 150 jobs, at least one freestanding clinic, specialty services like cardiology and neurology, and, of course, its emergency room. The nearest ER is now at least half an hour away.
The timing couldn’t have been worse. Pickens County Medical Center became the thirteenth Alabama hospital to shutter in less than a decade, just as other hospitals around the state mobilized to fight the growing epidemic, offering COVID-19 tests in their communities and treating waves of COVID-19 patients.
But Pickens County had a small group of local leaders who foresaw the hollowing out of their healthcare system and had already searched for solutions. A few local family physicians partnered with the county school system and public health researchers from the University of Alabama to open a new kind of school clinic in their medically underserved communities.
They’re called SMART Clinics — School Health Model for Academics Reaching All and Transforming Lives. In a SMART Clinic, nurse practitioners and physicians provide medical services like checkups and treatment of minor illnesses and injuries, while licensed clinical social workers offer counseling and behavioral health services.
So when the hospital closed and COVID-19 hit, three of the clinics were already up and running. A fourth opened soon after. They expanded their services to the entire community, offering COVID-19 testing, drive-through checkups and telehealth counseling during the pandemic.
Now, as communities in Pickens begin a slow march toward post-COVID normalcy, the SMART Clinics continue to fill in gaps in local healthcare.
Dr. Julia Boothe, a local family physician whose practice oversees the clinics, believes the model could work in other communities that have lost health services. The South has seen a sharp decline in rural healthcare providers in recent decades; more than half of all rural hospital closures nationwide since 2010 have been in Southern states.
“We’ve worked so hard to solve problems and figure out where all the issues are,” Boothe said. “I figured if I sit around and wait on somebody else to think of a way to do it, we may be sitting around a long time.”
Bridging the gap
Just beyond Main Street in tiny Gordo, Ala., the town’s K-12 public schools sit on one sprawling campus near the heart of town.
Gordo’s SMART Clinic can be found down a locker-lined corridor in the junior high building. The clinic doorway opens into a small but colorful waiting room with a receptionist’s desk. From there, the clinic branches off: behavioral health services to the left, medical services to the right.
To the left is the shared office of Alicia McGee and Laci Jones. Flower garland made of tissue paper brightens the cool gray walls; a big window overlooks a sunny courtyard. McGee and Jones are licensed clinical social workers who rotate among the county’s four SMART Clinics, providing counseling and other behavioral services.
Nearly every student at a SMART Clinic school in Pickens County has visited Miss Alicia or Miss Laci, as they’re affectionately known. They perform one-on-one behavioral assessments for every student, with parents’ permission. The assessment comprises a wide-ranging series of questions to get a general picture of the child’s wellbeing:
“Do you brush your teeth twice a day?”
“Do you like school?”
“Do you feel worried and stressed often?”
“Are you excited about growing up?”
“Do you feel safe?”
The assessments help McGee, Jones and other clinic staff identify needs that might otherwise remain hidden, they said. For some students, it might be untreated anxiety or depression. For others, it could be problems outside of school.
“We’ve found homeless students who nobody knew were homeless,” Boothe said. “These screenings have helped us impact not only the students, but their families.”
Alabama has one of the highest rates in the nation of children with at least one mental health disorder, according to a recent study of data from the National Survey of Children’s Health. Rates are also high in other Southern states, like Mississippi and South Carolina.
Worse, Alabama – like most of the South – has one of the highest percentages of children who lack needed mental health treatment. There are only about 113 mental health providers per 100,000 people in Alabama, the worst rate in the nation, according to data from the U.S. Department of Health and Human Services.
Briley Newman will be a senior at Gordo High School in the fall. When she was in eighth grade, she said, she was diagnosed with an anxiety disorder.
“Immediately, (doctors) were like, ‘We’re going to put you on medication,’ but that wasn’t what I needed,” Newman said. “I needed something like this. If (the SMART Clinic) would have been here at the time, maybe I wouldn’t have had to go on medication and experience all those weird side effects.
“Just talking to someone – that’s what most kids need.”
Students can visit the clinic during the school day, which means a parent doesn’t have to take off work to take a child to an appointment. All SMART Clinic services, including counseling sessions with McGee or Jones, are free to students. The clinic bills their health insurance if they have it, and a private foundation covers their co-pays. Community members who use the clinic are billed a co-pay.
Boe Hill, assistant principal at Gordo High and a Pickens County native, said the SMART Clinic brings resources to students they otherwise wouldn’t have – particularly the counseling sessions.
“A lot of times, students don’t want to tell their parents what’s going on,” Hill said. “They don’t really want to tell us as administrators either. So (the counselors) bridge that gap for us.”
This kind of easy-access intervention wasn’t available locally before the SMART clinics opened, McGee said. There’s a small mental health office in Carrollton, but it can take a while to get an appointment. The next closest option is to drive nearly an hour to Tuscaloosa.
And since most students get an assessment, there’s less stigma around going to the clinic for counseling, said Jones.
“We’re trying to destigmatize mental health for people who do come routinely for counseling,” said Jones, the social worker. “If everybody’s coming, you don’t know who’s coming for what.”
Why schools are ‘SMART’
Dr. John Brandon has been a family physician in Pickens County since 1981. Though he’s semi-retired now, he said he has always been interested in the potential for school-based clinics to fill in rural healthcare gaps.
“Healthcare in our rural areas is in a very precarious situation, mostly because of the hospital closures,” he said. “And there are limited physician offices here now because of our inability to expand Medicaid coverage beyond what already existed in this state 10, 20 years ago.”
Elected officials and many in the medical community have blamed Alabama’s rural hospital closures in part on the state’s refusal to expand Medicaid coverage. Most of the remaining states that have not expanded Medicaid coverage are in the South. The 12 non-expansion states have accounted for more than half of rural hospital closures nationwide in the past two decades, according to a University of North Carolina research program that tracks rural hospital closures.
With fewer hospitals and physician offices in rural areas, schools become a new easy-access point for health services in rural communities, said Brandon: “Small towns generally have a very vibrant school system and that tends to be the focus of the community.”
Around 2017, Brandon invited Pickens County Schools Superintendent Jamie Chapman to join him and a few faculty members from the University of Alabama’s College of Community Health Sciences to meet with Ginn Group Consulting, an Illinois-based firm that created the SMART Clinic model. Eventually Boothe joined them as the local physician who oversees the clinics. Brandon travels between SMART clinics in Pickens County, filling in where needed.
For each new SMART Clinic, the Ginn Group’s charitable partners, including CVS Health and Aramark, provide the first three years of startup costs. After that, the clinic must be financially sustainable.
That can be a challenge, particularly in rural areas which tend to have a larger portion of the population that’s low-income and qualifies for Medicaid. Because Medicaid reimbursement rates in Alabama are notoriously low, like in most states that have not expanded Medicaid, Boothe and her staff have worked to get the clinics federally designated as Rural Health Clinics. This designation increases the amount they can be reimbursed for services.
About 20,000 people live in Pickens County. It’s racially diverse compared to the rest of the state, about 56% white, 40% Black. But the median household income of around $40,000 falls well below the state average of $52,000.
Three of the four Pickens County schools that house SMART Clinics are Title I schools, a federal designation given to schools where at least 40% of students come from low-income families.
The percentage of students with private health insurance or state Medicaid varies by school, said Boothe. But she said she’s found that the services – especially behavioral health – are just as needed at the county’s middle-income areas as they are in lower-income schools.
“People think you need to put this where your socioeconomic at-risk kids are, which is true, but we’ve found middle class families are where kids are also at risk,” she said. When you stereotype the kind of kids who need services, she said, “you’re missing as many as you’re finding.”
‘This is their safe place’
Over on the medical side of the SMART Clinic at Gordo, nurse practitioner Marilyn Smith says she typically sees kids for allergies, minor injuries, medication refills and regular checkups.
If a student shows up in the clinic with a relatively minor complaint like a sinus infection, Smith can prescribe medication – with a parent’s permission if the student is under 14 – and send the student back to class; the prescription is available at a pharmacy when a parent or guardian can pick it up.
The clinic staff works with students’ primary care doctors, if they have them, as well as with the school nurse and guidance counselors. Staff can also make referrals to dentists, optometrists and other specialists.
Most, if not all, SMART Clinic staff members are from Pickens County or have deep ties there. It makes parents more comfortable to know the staff personally, said Kim Taylor, who coordinates Pickens County SMART clinic operations.
“Your staff in a SMART clinic is crucial,” said Taylor, who grew up nearby in Reform, Ala. “The kids know this is their safe place and that someone in the clinic cares.”
This summer, the SMART clinic in Carrollton is open for appointments for anyone in the community.
As Boothe and her staff look toward the upcoming school year, she said they’re looking at potentially expanding services, and how to make the clinics more financially sustainable by relying less on charitable donations. In the next year or so, she hopes to expand and open another SMART Clinic in Pickens County. There’s another one planned to open at a school in Jefferson County next year.
“The impact (of having a school-based clinic) is huge,” she said, “and that’s why we keep doing what we can to make them work.”