A CMS Program Designed for Physically Homebound Students is Now Surging With Mental Illness – Charlotte Magazine

The division was designed for a handful of students like Olivia – a 10-year-old with physical disabilities that prevent her from attending class. But now, the program has to serve hundreds.

Olivia Starr is like a lot of 10-year-old girls. She loves swimming, bubble baths, watching YouTube, and getting her nails done. She plays dress-up, and with her American Girl dolls. Her favorite Disney princesses are Belle and Cinderella, and she wants to be a dentist when she grows up. 

A fifth grader at Barnette Elementary School in Huntersville, Olivia’s learning about long division and the water cycle, and she just completed a biography project on tennis legend Billie Jean King. But unlike her peers, she can’t attend her school. It could kill her.

Olivia was born in 2013 with Charcot-Marie-Tooth disease—a genetic, degenerative nerve disorder—and mitochondrial disease. She has seizures, uses a G-tube, requires help to move her arms and legs, and depends on a ventilator to breathe. Any illness—something as mild as a cold or stomach virus—can threaten Olivia’s life. 

Teacher Joan Roberts works with Olivia one-on-one, in her Huntersville home or virtually, five days a week for an hour and a half. They’re part of a division of Charlotte-Mecklenburg Schools called Hospital & Homebound, which serves students in pre-K through graduation (or age 22, the maximum age that someone can attend high school in North Carolina) who cannot attend school in a traditional setting.

On a sunny Thursday in April, Roberts arrives at Olivia’s two-story home at 10 a.m. for class. She’s putting on her mask as Olivia’s mom, Crystal, swings open the front door. 

“Come on in!” Crystal says. “The princess will be ready in a minute.”

When CMS started the Hospital & Homebound program in the mid-1990s, it had only a couple of teachers and a handful of students. It was developed for students like Olivia with physical disabilities or illnesses—cancer, compromised immune systems, traumatic brain injuries—that prevent them from entering a school. It was never meant to grow.

But today, Hospital & Homebound has 24 full-time teachers, a social worker, and its own administration to serve a rising number of kids—about 350 in the 2022-23 school year—who need it. It still serves a segment of students with physical disabilities. A few others are there because they’re in trouble with the law for something like bringing a weapon to school. (Roberts met a former student, who wore an ankle monitor, in his local public library branch.)

But most middle and high school students in Hospital & Homebound are there because of mental health diagnoses. Social and health resources and services inside and outside CMS cannot keep up with the rapidly rising rate of mental illness among teens. As a result, hundreds of kids per year wind up in this program designed to be a last resort, and administrators believe it’s now one of the largest programs of its kind in the state.

When Roberts teaches Olivia at her home, the pair work in a small front room with floor-to-ceiling shelves that overflow with school supplies and toys. Among them is a wiffle ball launcher and a tablecloth that Roberts turned into a giant graph to teach Olivia how to plot X and Y coordinates. (Olivia can press a button to operate the ball thrower, which launches a Velcro ball at the Velcro-lined graph. Roberts came up with it to help Olivia physically and mentally engage with the subject.)

“Do you have that birdseed I brought last time I was here?” Roberts asks Crystal after arriving. Roberts will use the seed to help Olivia make a paper-cup bird feeder, a craft that doubles as an occupational therapy exercise. While Crystal’s gone to fetch it, one of Olivia’s two regular home-care nurses, Nurse Dan, pushes Olivia into the room in a hot-pink wheelchair.

“Good morning!” Roberts greets her. “You’ve got on such a great dress today! … Do you want to say hello?”

Nurse Dan pushes Olivia over to her desk. A device that looks like an iPad is mounted on a stand above it. Dan adjusts it so it’s eye-level with Olivia. It’s a Tobii Dynavox, an assistive communication device that tracks eye movement to allow a user to “click” on an item by fixing their gaze on it. Olivia is still learning how to use hers—it’s difficult, says Roberts, who’s tried it herself. 

After Olivia accidentally selects the wrong button a few times, she hits the one she’s aiming for: “Hi, my name is Olivia,” the tablet announces robotically. Since Olivia can’t speak, the Tobii offers her single-word answers and pre-programmed sentences. Without it, Olivia can answer simple questions with eye movements, head nods, and mouth clicks. (For example, Olivia flicks her eyes, head, or both to the right for “yes” and left for “no.” Given a list of options—do you want, one, the green dress; two, the pink dress; or three, the blue dress?—she blinks twice or makes two click sounds with her mouth to indicate that she wants the pink dress.) Because Roberts has worked with Olivia for almost four years, the two communicate as easily as if Olivia were speaking.

sOlivia Starr uses a Tobii Dynavox device, which tracks eye movement to allow her to “click” by fixing her gaze. The device then reads aloud what she clicks to help her communicate.CMS intends for students to use Hospital & Homebound temporarily, says program manager Tammie Holt, although a small number of kids like Olivia are long-term students. The amount of direct instruction each student receives varies. For Joan’s students, on average, it’s only three hours per week.

“It’s the most restrictive placement (in CMS). It’s drastically reduced access to learning, so we take the decision to put a child in it very seriously,” Holt says. “We really have to have proof that doing this is what’s best for a child, and we try to get them back into school as quickly as possible.” The approval process is lengthy, and parents or caregivers, the school district, and medical or legal professionals all must agree that the student is unable to physically attend school for at least 20 consecutive days.

Even though Hospital & Homebound students don’t attend their “home schools,” they’re still considered part of their classes and have access to all materials and assignments through an online portal. The program’s teachers determine what to spend their limited instruction time on and assess students’ understanding of topics, even if they cannot take traditional tests. Ideally, a student, parents, or both would work through additional assignments outside of class—but Holt says that rarely happens.

At Olivia’s house, Roberts logs onto her computer before class to access the materials from Olivia’s fifth-grade teacher at Barnett Elementary, Krista Fiorentino. On this day, Roberts introduces Olivia to the mathematical order of operations, and Olivia answers equations with her Tobii. After a break to make the bird feeder with the help of Nurse Dan, Roberts and Olivia read and discuss the first chapter of the children’s novel So B. It, a story about the 12-year-old daughter of a woman with disabilities.

CMS hired Holt, 42—a former school administrator and certified general curriculum, special education, and ESL (English as a second language) teacher—to expand and adapt Hospital & Homebound as demand grew. When she joined in 2019, the program had about a dozen teachers. That number has since doubled.

“We don’t really see a whole lot of variance in our number of students with cancer, traumatic brain injuries—that type of thing,” Holt says. “But what is continuing to skyrocket is our kids with mental health needs.”

In late 2021, the U.S. surgeon general declared deteriorating adolescent mental health a national crisis. Between 2001 and 2019, suicide rates for kids ages 10 to 19 jumped by 40% and emergency room visits for self-harm by 88%. Reports show that COVID worsened kids’ mental health, and the number of Hospital & Homebound students tripled during the 2020-2021 school year. Some were due to physical needs, like COVID complications or the increased risk for students with compromised immune systems. Many were due to mental illness. In response, the Hospital & Homebound team has broadened its reach this year to serve students in mental health day treatment facilities. 

Holt and her team often find themselves trying to fill gaps left by scant health and social service resources, both inside and out of CMS. District schools are supposed to follow a framework called MTSS (Multi-Tiered System of Support) to ensure that all a student’s needs are met—educational, social, emotional, physical. “There should be a team in each school that is identifying kids who need additional support and provide interventions to those students,” Holt says.

But not all schools are doing that effectively, and only some CMS schools have on-site mental health services. Even when they do, “sometimes those interventions work, and sometimes they don’t,” Holt says. Plus, schools can’t offer the range and level of therapeutic services that some students need. Families are left to rely on community-based organizations and private providers.

But even when they seek those out, Holt says, “Charlotte does not seem to have the therapeutic infrastructure to support the need, which is why we’re seeing more of these needs show up in schools.”

Before she was Olivia’s teacher, Roberts taught in various special education roles at South Academy of International Languages, a CMS language-immersion magnet school (formerly Smith Academy of International Languages and E.E. Waddell Language Academy), for a decade. During that time, she didn’t know about Hospital & Homebound.

“Teachers and parents often haven’t known it exists,” says Roberts, 56, “until they have a student who needs it.” 

Sometimes, they need it and still don’t know. In spring 2011, Roberts’ daughter was a senior at Northwest School of the Arts, a CMS magnet school, when she was hit by a car in the family’s South Charlotte neighborhood. (For privacy reasons, Roberts’ daughter asked not to be identified.) She sustained a traumatic brain injury, two torn ankle tendons, a fractured orbital socket, and severe mouth and facial trauma.

For months, her food had to be blended in a food processor as her mouth healed. She couldn’t walk as her legs healed. But the brain injury was the most agonizing. Symptoms lingered for years, and some are permanent.

As her brain recovered, Roberts begged her daughter’s school to get what she needed to finish the year. Teachers and administrators didn’t understand her limitations. Even as a longtime teacher, Roberts struggled to guide her.

“I remember us sitting in the dark because lights were a thing (my daughter couldn’t tolerate),” Roberts recalls. “She would lay in her bed, and I would lay on the floor with a pillow and a headlamp and read her schoolwork, and she would tell me the answers, and I’d write them down and turn it into her school.”

With Roberts’ help, her daughter graduated on time. She went on dual enroll at Central Piedmont Community College and UNC Charlotte, where she graduated summa cum laude with a bachelor’s in German. Today, she’s a K-6 teacher with a master’s degree. But not every student has a parent knowledgeable enough to navigate the system for their child, and the program could’ve taken immense pressure off an already overloaded family.

Roberts didn’t learn about Hospital & Homebound until 2017—six years after her daughter’s accident—when she saw a job listing for it in an internal CMS newsletter. That same year, Roberts began working for the program.

Hospital & Homebound hired Holt, its first dedicated manager, in 2019. She emphasizes that the program is meant as a last resort for students who need it, not just difficult kids. One of her jobs is to ensure that school staff—particularly counselors and special education case managers—know about Hospital & Homebound so that families who need it can access it. 

“We have also made it a point to make sure that there are some public-facing resources for the community and for families,” Holt says. “But it’s a fine line.”

Roberts’ job doesn’t end with Olivia’s day. Not only does she adapt future lesson plans and record Olivia’s progress, but she also works to ensure that Olivia has as many opportunities and adaptive tools as possible. She recently pushed CMS’ adaptive technology department to get Olivia a switch-operated electric mixer so she can help her mom in the kitchen. In March, she arranged for Olivia, her mom, and a nurse to take a multiday field trip to Washington, D.C., with Olivia’s class. Planning an overnight field trip is already complicated, but Roberts had to ensure that the travel and activities were safe and accommodating for Olivia. As of May, Roberts had eight other students, all with distinct needs, and her roster is constantly in flux as kids enter and exit the program.

Without a program like Hospital & Homebound, and without teachers and advocates like Roberts, kids like Olivia often get left behind, says mom Crystal. They’re typically grades behind and require extensions. Instead, “Olivia has grown leaps and bounds,” Crystal says, and is working at grade level.

The proud mom likes to tell a story about Olivia when she was in first grade. Another teacher showed Olivia two cards: On one, Olivia’s name was spelled correctly. The other had the letters of her name but scrambled. The teacher asked Olivia which card had her name on it. Olivia indicated, “both.” The teacher said, “No, Olivia, only one of these is your name. Which one?”

“She kept asking her, and Olivia would not budge,” Crystal recalls, laughing. “She’s too smart for her own good.”

TESS ALLEN is the associate editor.