Problem Addressed

• Undertreatment, poor treatment, and misdiagnoses: Across the Nation, racial minorities are less likely than non-Hispanic Whites to receive treatment for mental disorders and often receive poorer quality services when they do receive care.² Minorities are also more likely to be misdiagnosed. For example, African Americans and Latinos are more likely to be overdiagnosed for schizophrenia, while Asian Americans are more likely to be underdiagnosed for depression.³ These problems exist in the Boston area as well. In the 2004 to 2005 school year, Frederick Pilot Middle School social workers identified 200 students in need of mental health services, but only 40 had been successfully connected with services.⁴
• Long-lasting implications: Untreated trauma is associated with behavioral and mental health problems, such as anxiety, aggressive behavior, poor impulse control, and alienation.⁵ Untreated mental health disorders can lead to school failure, family conflicts, drug abuse, violence, and suicide⁶ (the fourth leading cause of death among youth aged 10 to 14 years²).

Description of the Innovative Activity

• System of financial support for children's mental health: CWC demonstrates a cost-effective way to support full-time clinicians in schools by leveraging blended funding, including public and private insurance, private philanthropy, and in-kind contributions through supportive infrastructure. CWC supports partnerships among nonprofit mental health providers, hospitals, public schools, and foundations.
• Community-based collaboration and partnership building: School–community collaboration is the cornerstone of this project. School personnel and several community service agencies collaborate to provide culturally and linguistically competent, school-based mental health treatment and support services for students and their families. CWC innovated a collaborative training model that produced New England's first two Somali social workers.
• Integrated services: CWC clinicians coordinate with school personnel, families, and other service providers to fully integrate treatment services, including individual and family psychotherapy, child psychiatry, family support services, case management, and consultations with teachers, school personnel, and families. Information provided in December 2012 indicates that current initiatives include the co-location in schools of home-based therapy teams and other supports; an emphasis on parent engagement in school-based treatment; expansion to East Boston, a primarily Spanish-speaking community of immigrants largely from Central America; weekly cross-agency supervision in evidence-based treatments for trauma and anxiety; and the direct purchase of services by schools for nonbillable and prevention services, such as student support and crisis intervention.
• School-based student mental health services: Mental health and other support services are provided at target schools on a daily basis during and after school to facilitate student access to therapy services. Beginning in 2012, support services for Medicaid-eligible children and families, including intensive care coordination, in-home therapy, therapeutic mentors, and family partners, either are located directly in CWC schools or have fast-track access via preferred provider relationships with partner mental health agencies in the community where the school is located.
• Payment for services, insurance assistance: Third-party payers are billed directly for clinical services, with uninsured families being provided with assistance in obtaining insurance coverage for which they may be eligible. The May 2011 report of the Executive Office of Health and Human Services states that 99.8 percent of all children in Massachusetts have health insurance coverage after recent health care reforms.⁷ For those who do not, free care is available through CWC's provider agencies.

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Innovator Disclosures

Results

• Many children served: Information provided in December 2012 shows that as of 2012, the program has provided more than 600 children with more than 16,000 total hours of billable services, as well as many nonbillable service hours. Of the children served, 25 percent showed symptoms of traumatic stress. Many of these children were referred for other reasons, meaning that their trauma symptoms had not been recognized.
• Financially sustainable: Billable hours for a total of nine mental health clinicians at three mental health agencies were monitored weekly and recorded monthly from November 2006 to June 2011. CWC tabulated the actual cost/loss to the provider and demonstrated the effectiveness of a modest subsidy to sustain services, not including costs for coordination, training, and evaluation. Information provided in December 2012 indicates that an analysis of year 1 co-locating in-home therapy services in schools has demonstrated that the model is financially sustainable without the need for additional subsidy.
• Trauma Systems Therapy: An analysis of 3 years of outcomes in children exhibiting traumatic stress symptoms demonstrated statistically significant improvements in the following areas: 34-percent improvement in children's ability to regulate emotions and dangerous behaviors, 36-percent reduction in incidents of repeated trauma exposure, 27-percent improvement in caregivers' ability to help the child.
• Positive results from ongoing evaluation: Outcomes analyzed include the following: 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 include utilization of treatment (length of treatment and number of sessions); racial and ethnic demographics; school outcomes, including attendance, grades, and test scores; and clinical outcomes using the Global Assessment of Functioning (GAF) scale and the Massachusetts Child and Adolescent Needs and Strengths (CANS) tool. Information provided in December 2012 indicates that CWC collected data on 232 students from 2006 to 2011. On average, children were in treatment for 2.2 years, and the majority of them showed an improvement in overall functioning. Statistically significant findings include the following:
  
  • Global Assessment Functioning scale: Improvement was seen in 70.8 percent of the children, with a mean improvement of 10.26 points, or more than one functional domain.
  • Child and Adolescent Needs and Strengths tool: The Behavioral/Emotional domain, the area that is most relevant to overall mental health functioning, showed that 64.9 percent of the children improved. The greatest improvement (73.9 percent) was associated with treatment lasting from 9 to 14 months. The Risk domain, the area pertaining to risk of harm to self or others, indicated that 60.3 percent of the children improved over the course of treatment. The greatest improvement (66.7 percent) occurred in the group that was in treatment for 6 to 8 months.
  • Family engagement: The more family engagement, the better the outcomes; of the students with more than 4 hours of family engagement (mean = 4.3 hours, which includes family therapy and consultations), 67.6 percent improved versus 43.8 percent of those with less than 2 hours. During the first 2 years of intensive focus on increasing family engagement in treatment, which included additional training for clinicians in family therapy and weekly monitoring of productivity, family engagement in school-based treatment increased by 80 percent, from 10 to 18 percent.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Development of partnerships among community providers: Three core providers initially agreed to provide the bulk of clinical services, and a fourth community provider has joined the expansion effort to East Boston. Ongoing recruitment efforts are aimed at cultivating new opportunities and a diverse network of professional and community relationships.
• Development of program model: School and community partners established a standard for quality school-based care that incorporates onsite services for children with approaches 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 his or her natural milieu (classroom, cafeteria, playground), attend Individualized Education Plan and student support meetings, 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 to assess the unmet mental health needs of their students and to ensure adequate confidential counseling space and school-based referral infrastructure.
• Training: CWC has trained school clinicians and interns, educators, youth workers, psychiatrists, community leaders, and other community partners in Trauma Systems Therapy. New clinicians receive a total of 12 hours of training in Trauma Systems Therapy and evidence-based treatment for anxiety disorders, and all clinicians receive up to 16 hours annually of additional training in evidence-based treatments. In addition to the weekly clinical supervision provided each clinician by his or her employer, CWC itself provides 2 hours per week of group supervision to ensure fidelity to the evidence-based models for treatment of trauma and anxiety disorders. Each school year, CWC provides professional development for teachers in recognizing and responding appropriately to children who are exhibiting symptoms of trauma.

Resources Used and Skills Needed

• Staffing: CWC provides each target school with a full-time, school-based clinician to provide counseling, support, and consultation with schools, families, and teachers. The clinicians are master's level mental health professionals with a hiring priority to match, as much as possible, the racial, ethnic, or linguistic composition of the client base.
• Costs: The estimated cost of program development was $50,000 for the first year. In addition, partner agencies provide in-kind services and leverage reimbursement through third-party payers. Beginning in September 2012, the schools are paying for one full-time equivalent master's level clinician to cover unreimbursed agency costs, a sum that was previously provided through private philanthropy. CWC anticipates that $1 million in grant funding for direct project expenses will support the project for 6 years.

Funding Sources

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, including coordination, training, and evaluation.
• 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. CWC was implemented in stages, building up to full capacity over 3 years.
• Engage the community: It is important to engage the community to address the "stigma" often associated with seeking mental health services and to integrate culturally informed 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 involved if their leaders are committed to finding innovative approaches to improve access to treatment by integrating full-time mental health services into schools.
• 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 an expansion of services reimbursable by Medicaid and other insurers or, alternatively, a differential rate of reimbursement for school-based mental health services; Federal, State, or local government funds; district support; and private philanthropies. Success in obtaining 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 generally in session less than 40 weeks per year.
• Establish an ongoing infrastructure of support inside the school: To be successful in identifying the students with unmet mental health needs and to generate a continual stream of referrals, parental consents, 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.
• Consider developing 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 revenue. 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 approximately 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 parental consents 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 attention 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, the delay in start date is not necessary.