School-based telehealth expands further in North Carolina
By Jennifer Fernandez
In a small room at Hillcrest Elementary School in Burlington, students can now meet with a doctor during the school day — virtually.
The school joins a growing network across North Carolina where students don’t have to leave school to be seen for physical or behavioral health needs.
Kristy Davis, chief student services officer for Alamance-Burlington School System Credit: Courtesy of Alamance-Burlington School System
Health advocates say that school-based telehealth care cuts down on absenteeism, ensures that students receive routine care that they might not otherwise be able to get, and can even boost test scores.
At Hillcrest Elementary, one student’s recent visit for a stomach ache turned out to be an underlying dental issue — an abscessed tooth.
“They could have been out of school for two or three weeks, but we were able to figure out what was wrong and get him the proper care,” said Kristy Davis, chief student services officer for Alamance-Burlington School System.
Enhancing access
The COVID-19 pandemic “propelled the adoption of telehealth in school settings,” according to the authors of a 2023 review of more than 30 studies on school-based telehealth.
“The perceived benefits derived from these interventions were substantial, augmenting traditional approaches, enhancing clinical care, and fostering collaborative efforts within families,” the authors wrote. “The implications underscored the enhancement of healthcare access, early anomaly detection, and the elevation of nursing leadership within the telehealth domain.”
Yet telehealth services in North Carolina schools came long before the COVID-19 pandemic, driven in large part by difficulties in accessing care in far-flung rural communities.
In North Carolina, Health-e-Schools began providing telehealth services to schools in the western part of the state in 2011. The program, an initiative of the Center for Rural Health Innovation, started with a handful of schools in two districts. Today, it serves more than 90 schools in seven western North Carolina counties and partners with 40 schools in four southeast counties.
In Guilford County, Cone Health launched its first telehealth clinic in 2021 at Bessemer Elementary in Greensboro through a partnership with Guilford County Schools and the Guilford Education Alliance. By spring of 2024, 14 low-income schools in the district were participating. Another 12 schools have been added this academic year.
Davis is already eyeing expansion in Alamance-Burlington.
“It is something that we want to put in more schools,” she said.
A new telehealth office at Hillcrest Elementary School in Burlington allows students to be seen by a doctor while at school. Credit: Courtesy of Alamance-Burlington School System
About 50 people, including several virtual participants, gathered at Union Square Campus to talk about growing school-based telehealth programs. The collaborative is made up of 17 partners — hospital systems, university programs and health agencies — from North Carolina, South Carolina and Virginia.
They shared what’s working or not working, and what they have coming up.
The programs use different models to provide care.
Cone Health uses a certified medical assistant as a “telepresenter” who is based in the school. Their program also involves parents in the visit, usually by sending them a link to their smartphone so they can participate.
The medical assistant/telepresenter gets about four weeks of additional training. They work full time, so they can act as a part of the school health team, said John Jenkins, medical director of Cone Health School-Based Care. Families must sign a consent form before students can be seen at the clinic. A provider, such as a pediatric nurse practitioner or a pediatrician, gets pulled in for cases such as an earache, upset stomach, injuries and colds, for example.
That provider can assess the child using special equipment handled by the certified medical assistant, “just as if they were in their own office,” Jenkins said. The Bluetooth-powered equipment allows the remote provider to visualize the ears, throat, heart and lungs of the patient and send a prescription to the pharmacy, if necessary. There are also some medications in the clinic that can be sent home with the child if prescribed.
“The vast majority, about 90 percent of the time, we would return children to class the same day,” Jenkins said.
In Guilford County Schools, 42 percent of students at the schools with clinics signed consent forms to participate, district data shows. That year, there were 3,174 clinic visits, which led to 1,440 virtual telehealth visits with a doctor or nurse practitioner.
Guilford County Schools officials have seen improved attendance at all of the participating schools, according to data shared at the telehealth conference. Two-thirds of the schools experienced a decrease in office discipline referrals on average for students participating in the clinic compared with those who were not. In addition, students who signed up for the clinics at many of the schools did better on end-of-grade reading and math tests than their peers.
The latest area of growth for the school-based telehealth collaborative has been in telepsychiatry for behavioral health issues.
The Improving Adolescent Child health Through Telepsychiatry in NC has been providing therapy and psychiatry telehealth care in schools for about two years. The program operates out of the Department of Psychiatry in the School of Medicine at UNC Chapel Hill.
Early data shows that 70 percent of patients reported improvement with depression, 86 percent improvement for anxiety issues and 69 percent improvement for children with attention deficit hyperactivity disorder, said Charissa Gray, program director of virtual care and integrated behavioral health at UNC Chapel Hill.
“Definitely people are showing improvement, so we want to continue to see these numbers grow,” she said.
Their program is continuing to evolve.
They’ve looked at enhancements such as rotating session times so a student isn’t missing the same class each week, or having someone available to speak Spanish, said Stephanie Brennan, a pediatrician and child and adolescent psychiatrist who works with the UNC Chapel Hill program.
They’ve also been flexible with who helps the student connect to the session. In some schools, that’s the school nurse or school social worker. In others, they give the school the money to hire a contractor to be there.
“And that’s been really working out beautifully. That person is part of the school culture,” said Alison Burke, a clinical instructor with the program. “They also make sure the technology is working well. And they’re also there outside the door in case we need them, in case there’s a crisis or anything like that.”
Donnie Mitchem, director of Atrium Health’s Behavioral Health School-Based Teletherapy talks about the program during the April 4 meeting of the Carolina School-Based Telehealth Learning Collaborative in Greensboro, N.C. Credit: Jennifer Fernandez / NC Health News
Charlotte-based Atrium Health also recently added school-based telepsychiatry, which is now available in 57 schools throughout the southern Piedmont.
A real “pain point” has been juggling the various schedules for schools, including early release days and teacher work days and other days off, said Donnie Mitchem, director of Atrium Health’s Behavioral Health School-Based Teletherapy.
She said in some participating schools the Atrium program will only see the commercial payers because they have somebody in house who sees Medicaid patients. In some schools, it’s the opposite.
Cone Health is in the process of adding behavioral health to its school-based telehealth clinics. They’ll pilot the program in a few schools first before expanding it, Jenkins said.
John Jenkins, medical director of Cone Health School-Based Care, holds a piece of the technology used by a certified medical assistant during telehealth visits. Credit: Courtesy of Alamance-Burlington School System
Community care
At the Greensboro conference, the keynote speaker encouraged members of the school-based telehealth collaborative to expand telehealth to the community.
Kathy Wibberly, director of the Mid-Atlantic Telehealth Resource Center, talks about extending school-based telehealth programs to the community during the April 4 meeting of the Carolina School-Based Telehealth Learning Collaborative in Greensboro, N.C. Credit: Jennifer Fernandez / NC Health News
Schools are often natural gathering places for communities, they have spaces to allow for private conversations, and they have the reliable technology access that many homes may not have, said Kathy Wibberly, director of the Mid-Atlantic Telehealth Resource Center. The federally funded center serves North Carolina, seven other states and the District of Columbia.
Expanding telehealth services to the community could include everything from helping families deal with nutrition education or mental health issues or abuse issues that are going on in the home, she said.
“Because if the students are healthy, but the family is unhealthy, the students aren’t going to stay healthy for very long,” Wibberly said.
Several of the North Carolina collaborative members said they are already expanding their services.
The UNC Chapel Hill telepsychiatry program will be offering therapy over the summer to school staff.
Jenkins said Cone Health’s program plans to partner with the hospital system’s virtual urgent care program to give teachers an opportunity to be treated while at school so they don’t have to leave for routine issues.
Davis, a former teacher, knows how beneficial that will be.
“That teacher that takes a half a day to go get their blood pressure checked, that’s a lot of instructional time missed as well,” she said. “If it’s something that they can go get it checked by the telehealth presenter and stay at work and just be gone for 10 minutes, that’s a win … for everyone.”
RFK Jr.’s federal health department cuts sow confusion, uncertainty and fear in North Carolina
By Rachel Crumpler, Rose Hoban, Taylor Knopf and Grace Vitaglione
When federal health officials announced late last month what top officials called a “dramatic restructuring” of the U.S. Department of Health and Human Services, Robert F. Kennedy Jr., the department’s secretary, claimed: “Over time, bureaucracies like HHS become wasteful and inefficient even when most of their staff are dedicated and competent civil servants. This overhaul will be a win-win for taxpayers and for those that HHS serves.”
Many within the federal health agency, including division leadership, are waiting to hear Kennedy’s plan for the restructuring beyond initial reports that some DHHS offices will be combined in a new “Administration for a Healthy America.”
Then came last week’s personnel cuts at federal health agencies. Now North Carolina-based health officials, researchers, nonprofits, advocates for the aging, domestic violence victims, substance users and more are struggling with uncertainty about the slashing of workforces, blockages to counted-on funding streams and the delivery of care to some of the state’s most vulnerable.
“There have not been clear descriptions of what any of this consolidation would look like,” said a federal health employee from North Carolina working in Washington who wishes to stay anonymous. Many federal employees and grant recipients have been reluctant to speak out for fear of reprisal against themselves or their employers.
“In fact, without very well thought through plans for that, the only impact is going to be increased fraud, waste and abuse, because you can’t just throw everything into one pot with four people overseeing it and hope everything goes well,” they said.
The federal employee said their department staff was cut significantly, and co-workers were having conversations among themselves about which funding streams they will need to revert to Congress because they don’t have enough hands to administer the funds properly.
Cutting federal workers is penny wise and pound foolish, the federal health employee told NC Health News. Many federal DHHS workers are at the height of their careers and have expertise in certain subject matters while accepting less pay than what they could receive in the private sector.
And as the DHHS cuts take shape, advocates, federal employees and state officials in North Carolina are scrambling to understand the changes and make the necessary adjustments to their workflows and service delivery.
No one to answer the phone
“I feel like we lost so many good people … like the average of between 15-20 years of experience that were all let go,” said a North Carolina-based employee with the Centers for Disease Control and Prevention. NC Health News also granted them anonymity for fear of job loss.
Sara Howe, CEO of Addiction Professionals of North Carolina, was walking the halls of Capitol Hill last week to educate elected officials from North Carolina on the importance of a federal funding stream known as the Substance Use Prevention and Treatment Block Grant. While Medicaid will cover certain aspects of addiction treatment, the block grant funding fills the gaps to pay for those services that help sustain someone in recovery long term.
Addiction Professionals of North Carolina Director of Public Policy Jarrett Patrick and CEO Sara Howe went to Capitol Hill to advocate for continued funding of the Substance Use Prevention and Treatment Block Grant during a time of great uncertainty as federal health funds have been cut and federal health and human services employees have been fired. Credit: Addiction Professionals of North Carolina
Beyond potential funding cuts to Medicaid or the block grant, Howe said she’s also concerned that in an attempt to increase efficiency, the federal health department will lose those who understand the needs of people with substance use. She also worried that with the changes, money initially designated for alleviating substance use could end up being spent elsewhere.
“If we homogenize this to one public health prevention model, you lose institutional knowledge and expertise,” Howe said. “My fear is there won’t be a focus on substance use.”
As Howe and her colleagues were meeting with staff on Capitol Hill last week, some of her fears were being realized across town where the staff at the Substance Abuse and Mental Health Services Administration, where staff was cut by one-third. It was already one of the smaller divisions within the federal DHHS.
As staff dwindles, Howe said, logistical concerns arise about federal grant renewals arriving on time, confusion about who will handle contracts and how money will get to the states, among other things.
If grant seekers have an issue, she wondered, would there even be someone at the federal DHHS offices to answer the phone? “When you take a hatchet so fast, you’re going to hit the main arteries and then you can’t bring it back,” Howe said.
Many of the federal grants go to nonprofit organizations or smaller county agencies that are the boots on the ground, she said. If checks are delayed or funding is cut, that will have real-world consequences in North Carolina.
Disruptions begin
In March, the state DHHS had to wrestle with the impact of a federal delay in the payment of $250 million in Medicaid funds. According to state officials, that delay postponed payments to local providers and organizations.
The loss of staff at the federal level can be disruptive to workflows and communication, said Kathleen Lockwood, policy director for the North Carolina Coalition Against Domestic Violence. The coalition is 90 percent federally funded — coming from a complex array of sources, including the CDC and the U.S. Department of Justice.
“We are concerned that even though the funds have been appropriated and our contracts are very much in place,” Lockwood said. “If there are no staff members to actually administer those funds, it will functionally turn into us not being able to receive them under our existing contracts.”
Carianne Fisher, the coalition’s executive director, explained that the organization is in year three of a five-year grant for domestic violence prevention through the CDC. Every year, an annual progress report is due that leads to a continuation application for the next year’s funding. Their year four budget is due in November, she said, but she’s now uncertain who will be reviewing it, as many of the staff they’ve worked with for years — and who were familiar with their work — have had their jobs eliminated.
“You build a relationship with your grant officer, and they know what the work looks like, so that when they review, they can ask questions based on the work that you’re doing … they know the big picture,” Fisher said. “New staff always have a learning curve, and this is particularly complicated work that folks are doing to prevent domestic violence.”
She worried it will be even more difficult for new people to step into the work when they are juggling new responsibilities taken on because of the downsizing.
Program cuts will affect services
Other advocates are concerned that without federal funding or oversight, agreements with the federal government will not move forward.
Money for home-delivered meals, in-home aide services, transportation assistance, housing and home improvements that allow people to remain in their communities, long-term care ombudsmen and congregate nutrition sites all flowed through the Administration for Community Living, said Mary Bethel, chair of the board of directors for the North Carolina Coalition on Aging.
Now, the remaining federal workers — likely without expertise — will have to take on the administration’s responsibilities. Bethel said farming out the work is troubling, as other agencies already have a huge burden and won’t have the focus or knowledge needed to run them as smoothly.
While no cuts to funding for those services have been announced yet, Bethel said she’s concerned that essential services will get lost in the mix. And even if the funding isn’t cut, the situation is daunting, she said. North Carolina’s demographer estimated last year that from 2021 to 2041, the state’s 65-and-older population is expected to grow from 1.8 million people to 2.7 million.
“With our older adult population increasing at such a fast rate, even if funding stays the same as it is today, then we’re still taking a cut,” Bethel said.
At the local level, Bethel said she’s heard concerns from some counties about continuing to provide services amid uncertainty of whether they’ll be reimbursed by the federal government.
“I’ve been in this business 50 years, and I have never seen people as anxious and stressed as they are now,” Bethel said.
Looming uncertainty
Uncertainty about what cuts could be coming next has put organizations on edge, in particular for those that rely primarily on federal funds. Part of the challenge is that the information that once flowed from trusted federal DHHS staff has been turned off.
The situation makes long-term planning impossible, such as for the 93 local domestic violence service providers across the state, said Lockwood from the NC Coalition Against Domestic Violence.
“All we can tell them is there is a disruption going on that we foresee could impact our access to federal funding,” she said. “We are all hands on deck asking for congressional action and asking for our state legislature to recognize the trouble to come.”
Lockwood’s organization surveyed all of the 93 domestic violence programs in the state to understand the stakes of potential federal cuts. Of the 43 programs that answered by early March, most reported they could only operate for an average of 60 days without federal funding.
“Their budgets are so razor-thin already that by the time they start to see or have actual funding impacts, we are already going to be looking at the potential of programs closing,” Lockwood said. “It will be too late at that point to reverse course without irreparable damage to at least a lapse in availability of services in communities across the state.”
For example, Lockwood said federal funding provides the foundation for domestic violence service providers to be able to offer 24/7 hotlines and emergency shelter for people fleeing an abusive partner, among other services.
Additionally, if the coalition lost all its federal funding, coalition executive director Fisher said she would have to reduce her staff from 19 full-time employees to just two.
She also said that many program leaders are turning to foundations and other private funders for support.
“It’s more competitive to receive funding from other funding sources because everyone’s scrambling,” Fisher said. “It feels like we’re in competition with our partners to provide services across the state. None of us want to do that. We know that everyone needs a menu of services, and a lot of the survivors of domestic violence have also experienced child abuse or have experienced sexual assault, and all victims and survivors deserve the services they need.”
‘Feels like a slap in the face’
Adding to uncertainty is the status of lawsuits over the cuts to funds and staffing. Jeff Jackson, North Carolina’s attorney general, joined 22 other states and the District of Columbia in filing a lawsuit last week in federal court in Rhode Island over the $11 billion in cuts to funding to states. Additionally, a federal judge said she will temporarily block billions in federal health cuts.
“There are legal ways to improve how tax dollars are used, but this wasn’t one of them,” Jackson added. “Immediately halting critical health care programs across the state without legal authority isn’t just wrong — it puts lives at risk. That’s why we’re going to court.”
But the courts move slowly, and the back and forth has taken a toll on service providers and on the federal DHHS employees themselves.
The anonymous CDC worker who spoke to NC Health News described being terminated in mid-March with a late-night email saying her dismissal was due to poor performance, even as her latest performance review said she achieved outstanding results. A second notice came to her personal email days later, saying she had been reinstated and should report to work the following day. Her supervisor had not been made aware of either action before they took place.
So far, though, she said she’s been lucky, as last week, more than 20 percent of workers were cut from the CDC and she was not among them.
“It is insulting, and it feels kind of like a slap in the face to say that we’re not qualified,” she said. “Especially that email that said we need to leave the unproductive public sector to live the American Dream by working in the productive private sector. It just felt like such an insult.”
“We know we’re making less money here than we could be making somewhere else. But that’s not why we’re doing it. We’re doing it to help people and to help people live healthier and better lives.”
NC Health News spoke to other federal health employees who said they feel underappreciated, sad and scared as their DHHS colleagues have been haphazardly fired. They anxiously wonder if they are next.
“This has happened so fast and so furiously that we’ve all been trying to sort of wrap our minds around what the heck is happening,” said Jane, one of the federal health employees based in North Carolina.
“We really need to shine a light on what looks to me like a tinder keg with federal employees’ health and well-being,” she said. “We’ve already seen suicide attempts, completion of suicide and someone who’s in the hospital with heart attack … not to mention mental health impacts for workers and their families.
“We’ve seen people starting to, sort of, melt down in the workplace.”
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In the wake of disasters, rural health could end up running on sunshine
By Will Atwater
When Hurricane Helene ripped through western North Carolina, it downed power lines, leaving tens of thousands of residents without electricity for days, even weeks.
Duke Energy reported “severe” infrastructure damage, including submerged substations, thousands of downed utility poles and fallen transmission towers. The company also noted that mudslides, flooding and blocked roads hampered efforts to quickly restore power.
At Duke Energy’s Marshall Substation in the town of Hot Springs, heavy rains and flooding forced the shutdown of the facility. But Hot Springs was more fortunate than most. In 2023, Duke Energy had installed a microgrid of solar panels and lithium-ion batteries to restore power quickly in case of emergency.
A microgrid is a self-contained electricity system that can operate independently of, or in coordination with, the main power grid. A common example is rooftop solar panels that supply electricity to homes, enabling residents to either disconnect from the main grid entirely or rely on it only as needed.
Hot Springs’ system, which can provide 100 percent of the town’s peak load and up to six hours of backup power, went live on Oct. 2, only five days after the storm. The microgrid operated continuously for the next 143.5 hours, providing power to the town’s center until power was restored to the area on Oct. 8.
The project, initially intended to be a proof of concept, worked to help the town get back online far ahead of its neighbors.
“It wasn’t as luxurious as a typical grid-powered home,” said Sara Nichols, energy and economic program manager for the Land of Sky Regional Council, a multi-county, local government organization. “It kept that town going when most people had nothing. It’s a huge success story.”
Hurricane Maria provides example
Rural and community health centers are a vital safety net for millions of Americans.
“As the largest primary care network in the nation, community health centers serve one in three people living in poverty — many in communities most impacted by environmental and climate hazards,” said Kyu Rhee, president and chief operating officer of the National Association of Community Health Centers, in a 2024 news release.
“Community health centers [are] not for profit organizations that receive a limited amount of federal support to provide care to anyone — [including] primary medical, dental, behavioral health, discounted Pharmacy [services] — and there in all 50 states and territories,” said Ben Money, from the association.
Money used to run the N.C. Community Health Center Association and knows the needs of this state well, including its extensive history of hurricanes disrupting power to crucial services. He pointed to Hurricane Maria, which devastated Puerto Rico’s power grid in 2017, as a turning point that accelerated efforts to equip health centers with solar-powered microgrids to improve disaster recovery.
In the aftermath of Hurricane Maria, which struck Puerto Rico in 2017, Casa Pueblo de Adjuntas — a nonprofit community organization — worked to diversify the energy grid by installing solar and microgrid systems across communities, providing power to homes, schools, businesses, and essential institutions. Credit: Casa Pueblo de Adjuntas
“The disaster in Puerto Rico was not the hurricane,” Massol-Deyá said. “It was the aftermath of the government’s [inability] to restore basic services and all the mismanagement of the situation.”
In the aftermath, Casa Pueblo used support from donors to help “democratize the energy grid” by installing solar and microgrid systems across communities — powering homes, schools, businesses and essential institutions.
“We have addressed health issues by building energy security,” he said, “because there’s a lot of people with chronic diseases — like high blood pressure, diabetes and respiratory issues — that require therapy and medication.”
Money echoed that point and emphasized the importance of keeping health clinics operational during and after emergencies.
“When community health centers are down, they can’t see patients,” Money said. “Those patients that need care end up going to the emergency room, where it costs an exorbitant amount of money to get something that could be delivered at a fraction of that cost at a community health center.”
“Each day a health center is closed due to a power outage puts the organization at a financial risk,” Money said, potentially leading to reduced services, staff layoffs or even permanent closure. By contrast, a solar microgrid system can lower operating costs, allowing centers to reinvest savings back into patient care and services.
The initiative targets rural health centers across the southeastern U.S., a region that experienced 474 weather-related power outages in 2022 — more than any other part of the country, according to the National Association of Community Health Centers.
The NACHC was also awarded a contract by the Department of Energy in 2024 to equip rural health clinics in North Carolina and other Southeastern states with solar microgrids. While the project is still in the planning stage, it is moving forward — despite federal funding cuts and increased scrutiny of Biden-era climate investments, Money said recently.
Advocating for microgrids
Long before Hurricane Helene battered western North Carolina, Sara Nichols had been working on ways to strengthen local power infrastructure in remote mountain locations — but she had struggled to gain traction with funders who denied multiple applications for support.
“We were working with designers and learning what projects needed — all the logistics,” said Nichols,whose organization serves four counties and 16 municipalities in western North Carolina.
Nichols said funders were hesitant to invest because the region lacked a history of major weather disasters.
“When I got a denial days after [Hurricane Helene] I was like, ‘Are you sure about that?’”
Despite being hundreds of miles from the coast and more than 2,000 feet above sea level, few expected the western North Carolina region to be so vulnerable. But Helene made one thing clear: No place is safe from severe weather.
As a result of Helene — and with the Hot Springs example in mind — Nichols and others have renewed their advocacy around communities — especially rural ones — to include microgrid technology in their resiliency planning.
“I feel like we may have better chances now being able to tie things to our hurricane relief work,” Nichols said.
‘Emerging technology’
While the microgrid in Hot Springs delivered power in the wake of Helene, Duke Energy spokesperson Logan Stewart cautioned that microgrids are still an emerging — and costly — technology. “They’re not the best solution in every situation,” she said.
“It’s kind of like a GPS in your car,” Stewart said. “If there’s an outage on your line, it’s going to just automatically reroute you to another line.
“We have [self-healing technology] integrated across about 60 percent of our grid in the Carolinas,” Sewart noted. “We’re going to continue to expand, but we have miles and miles of line, so it just takes [time] to do that.”
Stewart noted that self-healing technology is better suited for urban areas, where terrain is less of a challenge.
“Microgrids can be a solution,” she said, “but it depends on the community terrain, cost and several other factors. It’s something we’re going to continue to explore — because the performance during Helene was fantastic.”
Closures of EPA’s Regional Environmental Justice Offices Will Hurt Rural America
Environmental justice efforts at the ten U.S. Environmental Protection Agency (EPA) regional offices have stopped and employees have been placed on administrative leave, per an announcement from EPA Administrator Lee Zeldin earlier this month. Former EPA employees involved with environmental justice work across the country say rural communities will suffer as a result.
Before being shuttered in early March, the EPA’s environmental justice arm was aimed at making sure communities were being treated fairly and receiving their due protection under the Clean Air Act and Clean Water Act. Zealan Hoover, former senior advisor to the EPA administrator under the Biden administration, told the Daily Yonder that this work had big implications for rural places since there are pollution concerns in rural areas across the country.
“EPA was very focused on making sure that not just on the regulatory side, but also on the investment side, we were pushing resources into rural communities,” said Hoover.
According to Hoover, most of the pollution challenges the U.S. faces are not new. He said that the employees—now on leave—who staffed the EPA’s regional environmental justice offices were deeply knowledgeable on the issues affecting communities in their regions; issues which can go on for decades. Hoover said he worries about recent changes to the agency under the Trump administration, which also include a series of deregulatory actions and a proposed 65% budget cut.
“I trust that the great folks at EPA who remain will still try valiantly to fill those gaps, but the reality is that this administration is pushing to cut EPA’s budget, pushing employees to leave, and that’s going to restrict EPA’s ability to help rural communities tackle their most significant pollution challenges,” Hoover said.
One rural community that has faced years of environmental challenges is where Sherri White-Williamson lives in rural Sampson County, North Carolina. In 2021, the county’s landfill ranked second on the list of highest methane emitters in the U.S. The county is also the second-largest producer of hogs nationwide, and in 2022, it accounted for nearly three percent of all U.S. hog sales.
The hog industry is known for its pollution from open waste storage pits that emit toxic chemicals into nearby neighborhoods. For years, concerns about North Carolina’s hog industry have centered on the disproportionate harm that its pollution does to low-income communities and communities of color since hog farms frequently locate their operations adjacent to such communities in rural counties.
White-Williamson is also an EPA veteran. She worked on environmental justice initiatives at the agency’s Washington, D.C. office for over a decade before moving back home to southeastern North Carolina. She is now the executive director of the Environmental Justice Community Action Network, or EJCAN, which she founded in Sampson County in 2020 to empower her neighbors amidst environmental challenges like those wrought by the hog farms and the landfill.
In her early work with EJCAN, White-Williamson said she noticed that conversations about environmental justice often centered on urban areas. Since then, White-Williamson said she has focused on educating the public about what environmental justice looks like in rural communities.
“A lot of our issues have to do with what the cities don’t want or dispose of will end up in our communities,” said White-Williamson. “The pollution, the pesticides, the remnants of the food processing all ends up or stays here while all of the nice, clean, freshly prepared product ends up in a local urban grocery store somewhere.”
Another misconception about environmental justice, according to White-Williamson, is that it exists exclusively to serve communities of color. During her time at the EPA, White-Williamson said she spent time in communities with all kinds of racial demographics while working on environmental justice initiatives.
“I spent a lot of time in places like West Virginia and Kentucky, and places where the populations aren’t necessarily of color, but they are poor-income or low-income places where folks do not have access to the levers of power,” White-Williamson said.
When pollution impacts local health in communities without access to such “levers of power,” the EPA’s regional environmental justice offices were a resource—and a form of accountability. Without those offices, it will be more difficult for rural communities to get the services they need to address health concerns, said Dr. Margot Brown, senior vice president of justice and equity at the Environmental Defense Fund.
“They’re dismantling the ecosystem of health protections for rural Americans, and by dismantling them, they’ll make them more susceptible to future hazards,” Brown said of the Trump administration’s decisions at the EPA. “It will impair health and well-being for generations to come.”
Brown worked at the EPA for nearly ten years under President Obama and then under President Trump during his first administration. Her time there included a stint as Deputy Director of the Office of Children’s Health Protection. She, along with Hoover and White-Williamson, said that community members will likely need to turn to their state governments or departments of environmental quality in the absence of the regional environmental justice offices.
But White-Williamson noted that state governments, too, receive federal funding. Frozen funds across federal agencies and cuts to healthcare programs, including Medicaid, could wind up compounding challenges for rural communities trying to mitigate environmental health impacts.
“The communities that most need the assistance and guidance will again find themselves on the short end of the stick and end up being the ones that are suffering more than anybody else,” White-Williamson said.
Hoover described it as a “one-two punch” for rural communities. On the one hand, he said, rural places are losing access to healthcare facilities because of budget cuts.
“And on the other hand, they are also sicker because the government is no longer stopping polluters from polluting their air and their water.”
‘A slap on the wrist’: families and advocates call for increased accountability from assisted living facilities
By Grace Vitaglione
This article was written with the support of a journalism fellowship from The Gerontological Society of America, The Journalists Network on Generations and The Silver Century Foundation.
Kristin Goforth and Lauren Cox, twin sisters aged 49, moved their father into a Piedmont Triad-area assisted living facility on March 13, 2021. Rick Goforth, then 75, was in good health; he was an avid walker who enjoyed being outside. But he was exhibiting signs of dementia — he had wandered off twice — so they decided a facility specializing in memory care would be safest.
He entered the facility at the lowest level of care available, passing all the assessments for activities of daily living such as independent bathing and eating.
Two months later, Rick was dead.
Rick Goforth fell repeatedly in the assisted living facility and staff put him in a wheelchair against a wall. Credit: Goforth family
The sisters said they watched their father undergo a “drastic” decline in the facility; days after his arrival, he fell and broke his wrist. It turns out facility staff were giving Rick medicines the family hadn’t known about, including administering his usual dose of Xanax three times a day instead of his prior regimen of only once a day. Plus, he was getting extra “as-needed” doses.
Because of the broken wrist, he lost the ability to use a knife and fork, nonetheless the staff didn’t cut up his food for him, Kristin said.
Rick started falling repeatedly and staff put him in a wheelchair against a wall, with a table blocking him from moving.
Near the end of April, the family took him to the hospital – he was severely dehydrated, malnourished and in acute renal failure — “basically hospice-ready,” Cox said.
The sisters had difficulty finding justice for their father’s death. First, the family called the county department of social services, which said they didn’t find anything wrong at the facility. Then they complained to the state, which found the facility had violated regulations resulting in death or serious physical harm, abuse, neglect or exploitation of a resident. Eventually, the state fined the facility $19,000.
Cox called that “a slap on the wrist.” The family sued the facility and came to a settlement subject to a confidentiality agreement that limits Cox from being able to say more.
Advocates say Goforth’s story is an example of how the regulations overseeing assisted living facilities in North Carolina can be out of date, and public officials’ enforcement of those regulations can vary from county to county.
When officials do fine facilities for violations, facilities have the ability to negotiate those penalties down to very little, advocates said. A NC Health News analysis found that fewer than half of penalties levied in the last three years were paid in full by facilities.
Assisted living over time
In North Carolina, assisted living facilities are referred to as “adult care homes” or “family care homes.” There are more than 1,200 of these facilities in the state, according to the North Carolina Department of Health and Human Services, and they can range in size from family care homes — licensed to have two to six residents — to larger adult care homes licensed to have more, with some housing more than 100 residents.
Residents of these homes may need help with activities of daily living, such as eating, dressing and bathing. They may require 24-hour supervision, but they don’t need regular nursing care. These residents are supposed to have less-complex health needs than those in skilled nursing facilities, or nursing homes, where residents’ needs require regular medical intervention.
The severity of patients’ conditions in adult care homes has become more profound over the years, said Mary Bethel, board chair of the NC Coalition on Aging. People who in the past would have been placed in a nursing home now live in adult care homes, she said.
In recent decades, adult care homes were also the destination for many former psychiatric hospital patients when the state undertook a process of deinstitutionalization for people living in them, said Hillary Kaylor, an ombudsman who advocates for residents in long-term care in Mecklenburg and eight surrounding counties.
Many of the facilities weren’t prepared to take on that mental health population and weren’t given support to do so, she said.
“We over-built [the industry], we under-supported, and then we expected a lot,” she said.
Eventually, North Carolina’s overreliance on adult care homes to house psychiatric patients led to a settlement with the U.S. Department of Justice over improper institutionalization of mental health patients in violation of the Americans with Disabilities Act and the subsequent Supreme Court Olmstead decision.
‘Working with an old book’
Adult care homes are regulated primarily at the state and county level, whereas most nursing homes, which can receive Medicare payments, have to follow federal rules as well.
Kaylor said oftentimes, the rules for care in an adult care home are set by a contract between family members and/or residents and the facility, so the levels of care can vary. Some facilities may have a registered nurse there eight hours a day, and some may have one that only visits twice a week, for example, she said.
But as patients’ conditions in adult care homes become more severe, Kaylor said that might call for updated regulations to accommodate those changes.
“Sometimes we’re working with an old book,” she said.
There is an enhanced license associated with having a special care unit, or a secure wing specifically for dementia patients, said Elizabeth Todd, lawyer for the Goforth family. Her practice focuses on nursing home and assisted living negligence.
Facilities must apply for the enhanced license, which comes with higher staffing and training requirements. But some facilities can get around those rules by calling their dementia wing a “memory care unit” and just locking the door, she said.
In adult care homes, most of the regulations are pretty generic, Todd said.
In contrast, “there’s a regulation for everything in a skilled nursing facility,” she said. “I don’t want to call it the wild west in adult care homes, but it’s not far off.”
The rules governing adult care homes have to be “readopted” every 10 years; the most recent round was completed in 2025, according to a NC DHHS spokesperson. Many areas were strengthened in the last few years, including infection prevention and control, emergency preparedness, administrator and management requirements, and resident discharge requirements.
Jeff Horton, executive director of the NC Senior Living Association, an advocacy organization for adult and care homes, said regulations have become much more stringent over the last couple decades to keep up with acuity levels.
If the state were to increase requirements, such as requiring adult care homes to have registered nurses on staff, then the state should also increase reimbursements to facilities that receive public funds, Horton said.
Vacancies and turnover at the state level
Adult care homes are monitored by county departments of social services and the NC Division of Health Service Regulation through complaint investigations and annual surveys.
The state regulatory division had a 25 percent vacancy rate in March 2025 and a turnover rate of 11 percent in 2024, according to a NC DHHS spokesperson. In the past two years, that turnover rate was even higher.
Former Gov. Roy Cooper’s last four recommended budgets included additional positions for adult care surveyor positions, but the NC General Assembly didn’t put funds for additional inspectors into any of their final budgets.
Complaints to the state about adult care homes and family care homes have also increased, the spokesperson said. From 2020 to 2024, complaints rose over 22 percent.
At the county level, regulation can vary depending on resources, Kaylor said. For example, Mecklenburg County has staffers focused solely on adult care homes, but in more rural counties, social services staffers end up stretched thin.
Adult care homes in the eastern part of the state have complained they face stricter enforcement than those in the west, according to Horton. County social services staff in the east tend to be more aggressive and levy fines more readily, association members have told him.
New Hanover County Social Services Director Tonya Jackson said in a statement over email that the team works with staff from the state Division of Health Service Regulation to make sure all complaints are investigated and addressed promptly.
“Additionally, county staff participates in standardized state training each year to ensure a full understanding of rules and regulations,” she said.
The state division gives the same training to all county social services staffers who monitor adult care homes, said a DHHS spokesperson, and the state can provide technical assistance as needed. Situations can vary in each facility, so enforcement happens differently according to each specific place, the spokesperson said.
Bill Lamb, a longtime advocate for seniors, sits on the board of directors of the advocacy nonprofit Friends of Residents in Long Term Care. He said the wide variation in penalties and citations across the state shows that enforcement is inconsistent.
Lawsuits like the one pursued by the Goforth family are sometimes the only way to hold a facility accountable, Lamb said.
Yet even then, some facilities have clauses in their contracts that require residents or family members to agree to settling disputes through arbitration rather than in court. When a consumer signs admission papers for themselves or a loved one into a facility home, these clauses are often tucked among the dozens of pages of legalese in the contract.
Such provisions eliminate the opportunity for a consumer who ends up in conflict with a nursing home to go to court. Plaintiffs often win less money in these types of cases, Todd said.
That cap can make it harder for plaintiffs to find a lawyer who will take the case, which can take months or even years to pursue. Lawyers often are paid a percentage of the damages as payment, she said.
“The caps on damages is unjust primarily because there is absolutely no limit to the amount of damage these facilities can do, but there is a limit to what they have to pay for having killed people,” Todd said.
‘A leaky bucket’
When state or county inspectors find that an adult care home violated a regulation, they can levy a penalty. If facility administrators disagree with that finding, they can appeal through an Informal Dispute Resolution or go to the state Office of Administrative Hearings.
Fewer than half of the penalties levied against adult care homes in the past three years were paid in full, according to records from the N.C. Division of Health Service Regulation analyzed by NC Health News. Around 26 percent of the penalties were settled with the state, 11 percent were not paid and referred to the Office of the Controller, 13 percent were in the appeal process and 4 percent were blank.
Lamb said those numbers showed a lack of full accountability.
“That’s a pretty leaky bucket if you ask me,” he said.
Wealthier chains of adult care homes can “lawyer up” and drag out the appeal process, Lamb said, sometimes for years.
Using penalties effectively
The maximum penalty for a violation resulting in death or serious physical harm, abuse, neglect, or exploitation to a resident is $20,000 for an adult care home, licensed for seven or more residents. The facility can then be fined up to $1,000 each day the violation remains unaddressed.
“That’s what a life is worth in our state,” Lamb said.
Horton was previously a nursing home regulator, and he said there are times when regulators get things wrong — that’s why it’s important to have an appeals system. A settlement isn’t always bad, either, he said, as sometimes that means the penalty is waived in lieu of extra staff training.
Training can make more of a difference towards improving outcomes than a penalty, Horton said. Penalty dollars don’t flow back into any part of the long-term care system, though. They are designated — by law — to support the local school district.
While penalties can be a deterrent for breaking the rules, Horton said it’s important to look at the end goal of what they achieve in terms of improving care.
If the facility demonstrates a pattern of breaking the rules, state surveyors can suspend admissions, as well as downgrade, revoke or suspend their license, according to NC DHHS. If the facility has outstanding unpaid fees, the department will not issue them a new license or renew their license.
Despite her family’s settlement with her father’s facility, Kristin Goforth said she still doesn’t feel good about the situation — there should be better protections for older people. Lauren Cox said there should be more accountability for facilities overall.
“This can’t be the way we treat people who have spent their entire life contributing to society…they work, they pay their taxes, they do everything right, and then at their end of life, we do this?” Cox said.
Lost accountability
The state used to have a Penalty Review Committee, which evaluated proposed penalties for facilities that broke the rules, with representation from the industry, family members and advocates. The committee could recommend increasing or decreasing the penalty, as well as that staff receive more training. But the North Carolina General Assembly eliminated the committee in 2016, “blindsiding” advocates, Lamb said.
When the committee was operating, there was a significant backlog of penalties for review, a NC DHHS spokesperson told NC Health News. That created a delay of 9 to 12 months from the time a facility was cited with a violation to the time the penalty was finally imposed, as well as delayed information going on the agency’s website.
In North Carolina, Helene’s Destruction Underscores the Value of Homegrown Rural Health Care
Hurricane Helene wrought historic devastation when it hit western North Carolina last September. Nearly 100 people were killed in the region and thousands were left injured, traumatized or homeless.
Hundreds of volunteers arrived within hours and began assisting with everything from food delivery to housing to medical care. Their presence was a godsend. But for many of the area’s medical professionals, the crisis underscored their own advantage: They knew the place, the people, the culture.
“A lot of questions I don’t have to ask my patients, because I know already,” said family medicine physician Tim Bleckley, who returned to his hometown of Franklin after residency to take over the practice of a retiring doctor.
Rural Americans are more likely to suffer from, and die prematurely of, a number of chronic conditions, including cancer, heart disease and diabetes. Effective management of such diseases is bolstered by long-term doctor-patient relationships, and studies show that cultural awareness provides a firm foundation for these relationships.
Cultural awareness is, essentially, having an understanding of and being sensitive to a community’s customs and rhythms. For health care providers, it’s having a sense of what your patients arrive with when they enter your office.
Hurricane Helene reinforced Dr. Bryan Hodge’s conviction that the more local health care can be, the better. Photo by Taylor Sisk.
Bryan Hodge is chief academic officer for the Mountain Area Health Education Center. He’s tasked with convincing young health care professionals of the virtues of practicing medicine in a rural community. Hodge said in the storm’s aftermath, he felt “so much pride and inspiration for the way in which people showed up.”
He also witnessed “the value of knowledge of the fabric of a community.” Those attuned to its rhythms were uniquely well-placed. It reinforced Hodge’s conviction that “the more local the care can be, the better.”
A ‘Comfort Zone’
Health care administrators in Appalachia are striving to meet two objectives at once: addressing a critical shortage of providers by nurturing homegrown talent.
Case in point: Tim Bleckley.
Dr. Tim Bleckley returned to his hometown of Franklin in the mountains of Western North Carolina to practice family medicine. He’s committed to educating his patients about their medications. Photo by Taylor Sisk.
Bleckley was born with a heart defect and underwent surgery at a month old. While initially pediatric cardiology was his ambition, he changed his mind while in residency. He wanted to go home to Franklin, but knew the town was too small to sustain such a practice. So he chose family medicine instead.
His patients, he believes, are in a “comfort zone” when they visit him. They like that he’s aware of what they experience, how they operate, “the things that matter to them.”
“Primary care is very personal in terms of understanding where people come from, and understanding what their lives are like,” he said. “People are very comfortable with the fact that I’m a hometown boy who’s come home, and they feel very at ease coming to see me.”
He’s been able to translate that cultural awareness into change, one step at a time. He knew that his patients — like so many mountain folks — have a tendency to take the advice of their doctor without question. He wanted them to take more ownership of their care, to know why they’re taking a particular medication, when it should be taken and potential side effects. He uses the teach-back method to have them describe what they’ve been told about medications their cardiologist or nephrologist prescribed.
“I want them to feel confident they know what they’re doing.”
Rivers Woodward had a similar career trajectory.
When Woodward was a junior in high school, his sister was stricken with an illness for which traditional means of medicine proved inadequate. The family turned to Patch Adams — a physician with an alternative approach to medicine (and the subject of an eponymous motion picture starring Robin Williams) — and she made a remarkable recovery.
This experience inspired Woodward to pursue a career in health care, to help reinvent the way it’s delivered. Further, he wanted to realize that ambition in a rural community.
Like Bleckley, Woodward was raised in Franklin, in rural Macon County. Today, he’s a family medicine physician at Blue Ridge Health, a federally qualified health center in the town of Lake Lure, in the same mountain region in which he was raised.
In the days immediately after Helene struck Western North Carolina, Dr. Rivers Woodward and his Blue Ridge Health colleagues saw patients at a makeshift clinic in a nearby grocery store parking lot. Photo by Taylor Sisk.
Studies show that those who were raised in a rural community or trained in one are more likely to practice in a rural region. Both are true of Woodward. While in medical school at the University of North Carolina, he was selected for the Rural and Underserved Scholars Program, a collaboration of the University of North Carolina and the Mountain Area Health Education Center.
“Things move at a different pace” in a rural community, Woodward says. His sense of that serves him well. His cultural awareness provides a foundation from which he offers empathetic care, which, he says, entails “listening with curiosity because I actually want to know someone’s experiences.” It requires listening without judgment.
Regardless of where you come from, rural cultural awareness can be learned with time and patience, assuming you’re receptive to it. But for many, it requires a reset.
“The more insular your upbringing,” Woodward says, “whether that’s in New York City or in Macon County, the more difficult it is to tap into cultural humility with people who may not look like or speak like or think like you.”
Woodward’s upbringing was an unconventional one; learning was experiential. His family took extended trips through Latin America, traveling by bus, staying with local families.
At times, he felt tensions in his relationship with his hometown: that he was somewhat “other.” He says his practice of rural medicine, listening with curiosity, has allowed him “to heal that tension.”
Designing a New Model
In reflecting on his community in the weeks since the storm, Woodward references a paper written for the Episcopal Relief and Development agency on the emotional stages of a community that’s experienced a natural disaster.
“There’s a peak immediately afterwards that’s fueled by adrenaline and cortisol,” he explains, “survival mode, basically.” Next is “this feeling of the community coming together and supporting each other, which we saw.
“But then after that, there’s this long downhill slide into disillusionment, before the upward slope of rebuilding.”
There’s much work to be done in Western North Carolina. Its health care needs, like those of most of rural America, are urgent; solutions require systemic change.
Blue Ridge Health provided critical services and support in the aftermath of Hurricane Helene. Photo by Taylor Sisk.
Bryan Hodge recalls so many people being overwhelmed by the attention they were extended in the aftermath of the storm. They were accustomed to going without. This underscored for him the critical need for an overhaul of rural health care. And it underscored the heightened importance of cultural awareness to inform that overhaul.
Woodward was recently named Blue Ridge Health’s associate chief medical officer. One of his primary responsibilities is to help design new systems of care for its rural clinics.
“My hope is to leverage all of the resources we have within a really large organization to make sure that we’re meeting people where they’re at, regardless of their location and their condition,” he says.
This could mean, for example, recognizing what a huge issue transportation is in rural communities and taking better advantage of telehealth, or providing more home visits.
Tim Bleckley’s immediate community was spared from major damage in the storm. But a number of his patients live in communities that weren’t. The morning after, he was on the road, checking in on those he couldn’t contact.
“These are people I know,” Bleckley says. “They’re not numbers.”
He plans to continue to practice medicine in his hometown, using his cultural knowledge of the place to improve care, one patient at a time.
“I never regret or feel like I should have done this differently. Not at all.”
