Mental Health

Results

Post-implementation data suggests that Connecting With Care has enhanced access to needed mental health services in a population that has limited means of accessing such services. A formal evaluation of the program is ongoing but not yet completed.

• Many children served: As of 2009, the program has provided over 190 children with more than 4,000 total hours of billable services (with many more unbilled hours). Between 20 and 25 percent of all children referred to the program by partner schools show symptoms of traumatic stress. Many of these children were referred for other reasons, meaning that their trauma symptoms had been going unrecognized.
• Ongoing evaluation underway: The evaluation plan delineates desired program outcomes and measurement strategies. Outcomes to be tracked include the following: the community’s ability to provide child mental health services, the viability and desirability of using a blended funding model for school-based mental health providers, reductions in disparities in mental health care, and improvement in children’s mental and behavioral health. Key metrics to be used include utilization of treatment and followup services, demographics, school attendance and suspensions, and behavioral, functional, and family systems status (through use of established assessment tools). Adjustments will be made as needed during the first 4 years to improve program effectiveness.

Evidence Rating (What is this?)

Suggestive: Evidence consists of post-implementation utilization data, with the underlying assumption that in the absence of this program, the target population would not have had access to the services provided.

Context of the Innovation

Connecting With Care was developed in response to community activism after the creation of the community-organized New Boston Pilot Middle School (renamed in 2007 as the Lilla G. Frederick Pilot Middle School). Grove Hall, a neighborhood that borders Dorchester and Roxbury, is characterized by high crime, poverty, and low rates of educational achievement. Frustrated with the current educational system serving neighborhood children, community members worked together to organize the building and operation of a new facility in the heart of Grove Hall, which serves not only as a school, but also as a community center for public and private gatherings by area residents. Once the school was in operation, community members turned their attention to the special mental health needs of students at both the new school and other area schools adversely affected by repeated exposure to trauma due to the high rates of violence and gang activity in the area. This group of motivated community members, led by the Alliance for Inclusion and Prevention, worked together to create a plan to provide school-based mental health services through community collaboration.

Planning and Development Process

Key steps in the planning and development of this community-based and community-driven project are highlighted below:

• Developing partnerships among community providers: Three core providers initially agreed to provide the bulk of clinical services, with additional community providers being added over time. Ongoing recruitment efforts are aimed at cultivating new opportunities and a diverse network of professional and community relationships.
• Establishing a Community Guidance Board: Community activists collaborated to convene key community stakeholders to serve as program advisors. Board members, who represent multiple areas of influence, are rooted in the Grove Hall community.
• Development of program model: School and community partners established a standard for quality school-based care that incorporates onsite services for children with vehicles for working with the entire family. The model offers time for one-on-one therapy plus the capacity for clinicians to do the following: consult with teachers and other important people in the child’s life, observe the child in natural milieu (classroom, cafeteria, playground), and relay relevant clinical information and key decisions about the child in weekly clinical meetings.
• Development of request for proposal to recruit schools: Led by the Alliance for Inclusion and Prevention, community partners collaborated on the development of a request for proposal to solicit participation from schools in the targeted neighborhoods.
• Training: Connecting With Care trained school clinicians, educators, youth workers, psychiatrists, community leaders, and other community partners in trauma systems therapy. School staff received 40 hours of trauma training.

Resources Used and Skills Needed

• Staffing: Connecting With Care provides each target school with a full-time, year-round, school-based clinician to provide culturally competent mental health services and case management to students and families and to coordinate with school personnel and outside service providers to maximize benefits to clients. Clinicians spend approximately 75 percent of their time at their assigned school, with the remaining time allocated to the evening family clinic at the hub school site. These individuals are qualified master’s level clinicians with characteristics matching the racial, ethnic, and/or linguistic composition of the client base. In 2009, all Connecting With Care staff works at the Evening Family Clinic as well.
• Costs: The estimated cost of program development is $50,000, and the current annual Connecting With Care operating budget for five schools is $250,000. In addition, partner agencies provide in-kind services and leverage reimbursement through third-party payers. Connecting With Care anticipates that nearly $1,000,050 in grant funding for direct project expenses will support the project for 6 years (1 year of planning and a 5-year demonstration project). An ongoing evaluation of the program estimates the cost to schools of providing full-time school-based services to be between $4,000- 8,000 per 1.0 full time equivalent (FTE) of Master’s level clinical services per school (May, 2009).

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Funding Sources

Blue Cross Blue Shield of Massachusetts; Robert Wood Johnson Foundation; Amelia Peabody Foundation; The Boston Foundation

The first 5 years of the program are being funded by direct and leveraged grants from private and public sources as well as third-party payers. Grant funding was provided by Blue Cross Blue Shield of Massachusetts Foundation’s “Closing the Gap on Racial and Ethnic Disparities in Care” program, The Robert Wood Johnson Foundation’s Local Initiative Funding Partners program (matching funds), the Amelia Peabody Foundation, and The Boston Foundation. On the expiration of the current grants, the program is expected to be sustained through municipal and government funds and additional health insurance payments.

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Getting Started with This Innovation

• Secure buy-in and commitment from key stakeholders: It is critical to secure strong buy-in at multiple levels of the school district (e.g., principal, central office, student support services). Achieving this buy-in can be facilitated by demonstrating the ability of school-based mental health services to help in reaching the district’s goals of improved academic achievement and a better school climate. It is also important to secure dedicated service providers who are willing to make long term commitments.
• Secure a funding mechanism: A funding mechanism, such as grant funding or district support, is necessary to pay for any differential between reimbursement from third-party payers and the actual costs of providing quality services.
• Implement the program gradually: Because of the complexities involved with recruiting community partners and coordinating activities among multiple partners, it is useful to implement the program over a period of time. Connecting With Care is being implemented in stages, building up to full capacity over 2 years.
• Engage the community: It is important to engage the community to address the “stigma” often associated with seeking mental health services.

Sustaining This Innovation

• Engage in ongoing recruitment of community and school partners: Because partner responsibilities and priorities may change over time, ongoing recruitment of additional community partners can help to maintain program momentum.
• Recruit partners committed to long-term systemic reform: Partners are more likely to stay committed if their leaders are committed to long-term systemic reform.
• Actively pursue alternative funding sources: Because public funding can shift with new budget priorities and grant funding is usually time-limited, active pursuit of alternative funding sources, including third-party reimbursement, is essential. Potential sources of funding include Medicaid “differentials” for reimbursement for school-based services; Federal, State, or local government funds; district support; and private philanthropies. The active pursuit of alternative funding sources may require engaging public leaders and policymakers. Outside funding is especially important when using full-time (i.e., 12-month staff) for the school-based positions, because schools are in session roughly 38 weeks per year.
• Establish an ongoing infrastructure of support inside the school: In order to be successful in generating a continual stream of referrals, parent permissions, and collaboration with school staff, the partner school needs to provide a consistent referral coordinator and the school leader needs to be committed to the success of the services and the program (added May 2009).
• Consider development of a shared-risk model: The major barrier to participation for community social service organizations is the financial risk they take by using a model that employs full-time, salaried counselors but that relies primarily on third-party insurers for revenues. In addition to seeking grant funding, participating organizations may want to consider developing a shared-risk model to ensure that no one organization bears the brunt of the financial risk if third-party reimbursement does not match program costs.
• Consider carefully the timing for onset of services: From a practical and therapeutic perspective, it is often best to start the clinician in the school about 3 or 4 weeks after the school year begins. This delay gives school staff time to identify children in need of services and to prepare referrals and related paperwork (e.g., obtaining parent permission and insurance information), so that clinicians can start providing services as soon as possible after their arrival. In addition, schools typically use the first few weeks of the year to establish routines and set expectations. As a result, it is generally not feasible for school personnel to divert their attentions to nonclassroom professionals before they have classrooms and instructional practices organized and under control. In subsequent years, when clinicians are known and are carrying over existing caseloads, such delays may no longer be necessary.