STEPHANIE S. DANIEL, PH.D. PROFESSOR, DEPT. OF FAMILY AND COMMUNITY MEDICINE, WAKE FOREST SCHOOL OF MEDICINE PRESIDENT, BOARD OF DIRECTORS NORTH CAROLINA SCHOOL-BASED HEALTH ALLIANCE EXECUTIVE DIRECTOR SCHOOL HEALTH ALLIANCE FOR FORSYTH COUNTY OCTOBER 14, 2015 School Resource Officers and the School-Based Health Center

Objectives Briefly define school-based health centers and summarize school-based health center outcomes and benefits Provide an overview of The School Health Alliance for Forsyth County (SHA) Describe current programs and services of the School Health Alliance (SHA) for Forsyth County 2

Definition of School-Based Health Centers SBHCs are partnerships created by schools and community health organizations to provide on-site medical and mental health services that promote the health and educational success of school-aged children and adolescents SBHC providers work collaboratively with other service providers in the school and community SBHC are typically staffed by an interdiscplinary team of medical and mental health professionals that provide medical, nutrition, mental health, and health education services 3

Definition of School-Based Health Center A health center located on a school campus (school-based) or affiliated with schools in the community (school-linked) Require parents to sign written consents for their children to receive the services offered by the health center Monitored by an Advisory Committee to ensure compliance with standards, evaluate services offered, and make policy recommendations SBHCs are supported by local, state, and federal public health and primary care grants, community foundations, students and families, and reimbursement from public and private health insurance 4

Definition of School-Based Health Center SBHC services can include: 1. Well-child visits or care including immunizations 2. Primary care for acute and chronic health conditions 3. Mental health services 4. Substance abuse services 5. Case management 6. Dental health services 7. Nutrition education 8. Health education and health promotion 5

Rationale for School-Based Health Center Services as “Best Practice” SBHCs increase children and adolescent’s access to health and mental health services and overcome many of the barriers (e.g., financial/economic, transportation, cultural, geographic, and other family circumstances) associated with getting health/mental health services School-based health centers provide services to students, regardless of their ability to pay Decreased stigma associated with receiving services in SBHCs relative to community health centers/providers (students are times more likely to come to a SBHC for mental health services than a community health center or other community provider) 6

Rationale for School-Based Health Center Services as “Best Practice” Unmet mental health needs and physical health problems are substantial barriers to school learning and academic success for children and adolescents (Brown and Bolen, 2008).Brown and Bolen, 2008 SBHCs are widely recognized as a critical resource for evaluation and treatment of mental (and physical) health needs among school children and adolescents (Taras and H.L., 2004; Kopec, Randel et. al., 2010; Pediatrics 2012)Taras and H.L., 2004Kopec, Randel et. al., 2010Pediatrics 2012 SBHCs offer quality health and mental health services and are recognized for using an integrated strategy for addressing health and mental health issues SBHC services provide an opportunity for early identification and treatment of health and mental health problems and concerns 7

State and National Associations for SBHC State-North Carolina School-Based Health Alliance (NCSBHA) National-National School-Based Health Alliance: Both organizations advocate for policies, programs, and funding to expand and strengthen SBHCs, while also supporting the SBHC movement with training and technical assistance 8

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North Carolina is currently home to over 90 school health center sites serving 25 of NC’s counties.

SBHC Outcomes and Benefits Improved academic functioning and success 1. Decrease in absenteeism/Increase in attendance 2. Decrease in tardiness 3. More likely to stay in school/graduate 4. Higher ratings of academic expectations, school engagement, and safety and respect relative to schools without a SBHC 5. Declines in discipline referrals (85% decline in Dallas for students who received mental health services in a SBHC) 12

SBHC Outcomes and Benefits Cost-Savings 1. Reduced inappropriate emergency room use 2. Reduction in hospitalizations 3. Reduction of after-hours care/visits 4. Reduction in Medicaid expenditures 5. Significant increase in health care access by students who used SBHC (71%) compared to students without access to a SBHC (59%) 13

Overview of the SHA The School Health Alliance for Forsyth County is a partner and supporting organization to the Winston- Salem/Forsyth County Schools (WS/FCS). We work in collaboration with local health and human service agencies, parents, and educators to serve our WS/FCS students. As a non-profit, tax exempt organization, we are committed to improving child and adolescent physical and mental health in Forsyth County through health system changes and the development of new health services with the end goal of achieving both positive health and educational outcomes for our WS/FCS students. 14

Forsyth County’s SBHC History Spring Forsyth County School Health Initiative received RWJF grant March Independence High School SBHC opened (Total Care Center) April Mineral Springs Elem. & Middle School SBHCs opened (Bulldog) Dec School Health Alliance for Forsyth County nonprofit formed August Ashley Elem. & Atkins Middle School Wellness Centers opened June Independence High School and SBHC closed August Enhanced mental health model opened at North Forsyth High School April Meadowlark Elem. & Middle School Wellness Centers opened June Meadowlark Elem. & Middle school Wellness centers closed Dec Mental Health Consultation Clinic at WSPA opened, serving students > 10 June North Forsyth High School enhanced MH model closed August Mental health Consultation Clinic at WSPA expanded to serve students ages 5 to 9 August 2011-School-Based Social Work Program started to provide mental health screenings at all WS/FCS and mental health treatment at 19 new schools in Forsyth County September 2013-Mobile Medical Unit 15

Overview of the SHA Our mission is to improve the ability of students to learn by improving the health and safety of Forsyth County’s school-age children and adolescents through the provision of direct services and by coordinating and targeting the efforts and resources of all types of community health care providers. 16

Overview of the SHA As of January, 2004, the SHA also serves as the School Health Advisory Council (SHAC) for WS/FCS, providing guidance on policy issues that affect students’ health, in accordance with North Carolina statutes. Since assuming the role of SHAC, the SHA has also become a forum for addressing community health issues relevant to school-aged children and adolescents and developing health policy recommendations for WS/FCS. 17

Current SHA Programs The SHA currently operates and evaluates health centers representing 5 models of school-based health care: 1) A comprehensive health center serving Mineral Springs Elementary School and Mineral Springs Middle School, providing medical and nursing care, mental health care, and nutrition services to enrolled students; 2) Wellness centers serving Ashley Elementary and Winston-Salem Preparatory Academy at Atkins, consisting of a registered nurse and a licensed clinical social worker, working together; 18

Current SHA Programs 3) A mental health consultation clinic (MHCC), providing psychiatric consultation, care planning, and therapy services for children referred by school personnel, juvenile justice, or primary care providers; 4) School social workers providing mental health assessment and treatment services on site at designated schools (SHA School-Based Social Work Program). 5) A mobile medical unit (MMU) at Carver High School, North Hills Elementary, Main Street Academy, and Parkland High School providing medical care and mental health screening for enrolled students with the goal of connecting/reconnecting students to their primary medical and/or mental health home. MMU is operated in partnership with WSSU, Northwest Community Care Network (NCCN), and Downtown Health Plaza (DHP) 19

Current SHA Programs 6) Cross County Collaborative (use of Adolescent Questionnaire/Rapid Assessment for Adolescent Preventive Services-RAAPS) 20

Number of Schools in the WS/FCS District As of February 25, 2015 Elementary – 43 Middle – 14 High – 15 Non-Traditional/ “Special Schools” – 9 Total of 81 schools, serving 54,000 students 21

SHA Evaluation and Research In order to measure whether the SHA has accomplished its mission and to inform quality improvement efforts, the SHA has an evaluation and research plan, approved each year by the SHA Board of Directors. This plan is developed and carried out by the SHA evaluation team. 22

EVALUATION DATA FOR SHA PROGRAMS We review and summarize the following data: 1. Referral sources 2. Demographics and psychiatric diagnoses 3. Service utilization 4. Vanderbilt Assessment Scale (Teacher Reports) 5. Strengths and Difficulties Questionnaire (SDQ) Parent and Youth report 6. School grades, attendance and discipline data 7. Program Satisfaction Data (Parent, Youth, Teacher and Provider Reports) 8. Risk Assessment Data (Adolescent Questionnaire/RAAPS/PHQ-9- A) 9. Program Specific Outcomes

Other Evaluation Efforts for the SHA Examples of other data collection tools and efforts used by the SHA (past and current):  Pediatric Symptom Checklist  CRAFFT  CAFAS (Child and Adolescent Functional Assessment Scale)  Child Behavior Checklist  Medicaid Claims data (e.g., Emergency room visits, hospitalizations, connecting/reconnecting with a medical home) 24

Productivity by Site/Program Over Time All Sites 25 All Sites Combined Totals SY 2006/2007 SY 2007/2008 SY 2008/2009 SY 2009/2010 SY 2010/2011 SY 2011/2012 SY 2012/2013 # Users2,0241,8821,9041,5381,393 1,5411,536 # Visits7,9037,9787,2147,9397,214 7,5927,236 # Immunizations ,2801,6321,153 1,3451,192 # Risk Screenings ,9551,148 1,1521,053 # Mental Health Visits2,1622,1492,0203,0162,350 2,4732,026

Unique Visits by Site by Visit Type Unique Visits by Site Mineral Springs Student Health Center Winston- Salem Preparatory Academy Wellness Center Ashley Wellness Center Mental Health Consultation Clinic Ages Mental Health Consultation Clinic Ages School-Based Social Work Program Visit TypeFY12FY13FY12FY13FY12FY13FY12FY13FY12FY13FY12FY13 Medical2,7882, ,0041, Mental Health1, Total Count3,8433, ,0871,4691, All Sites Combined Visits by Type Visit TypeFY12FY13 Medical Visits4,4974,531 Mental Health Visits3,0952,705 Total Count7,5927,236

Mineral Springs Student Health Center 27

Winston-Salem Preparatory Academy Wellness Center 28

Ashley Elementary Wellness Center 29

School Health Alliance for Forsyth County Staff Stephanie Daniel, Ph.D., Executive Director Leigh Howell, M.D., Medical Director Sheila Whisenant, MHCC Coordinator and Mobile Medical Unit Coordinator Palmer Edwards, M.D., MHCC Psychiatrist Matthew Hough, D.O., MHCC Psychiatrist Karen Virga, R.N., Clinic Nurse Maureen Haynes, R.N., Clinic Nurse Michelle Butler, NP, Mobile Unit Nurse Practitioner Michael Pesce, LCSW, WS/FCS Director of Social Work Department, and SHA School-Based Social Work Program 15 LCSWs (SBSWP) Ron Lean, Ph.D., LCSW, Mental Health Provider Karen Pearson, LCSW, Mental Health Provider Tracy Bradshaw, Practice Manager Pamela Benton, Medical Office Assistant Lisa Rankin, Medical Office Assistant Becky Butcher, Medical Office Assistant Katie Catton, M.A., ADHD Project Assistant Andrew Mayfield, MMFT, Evaluator Lyn Treadway, M.A., Evaluator 30

Current Partner Organizations/Agencies Winston-Salem/Forsyth County Schools Administration – Faculty – PTA Council – Food Services Wake Forest School of Medicine  Dept. of Pediatrics  Dept. of Family and Community Medicine  Dept. of Psychiatry Northwest Community Care Network CenterPoint Human Services Forsyth County Department of Public Health Forsyth-Stokes-Davie County Medical Society Wake Forest Baptist Medical Center (Downtown Health Plaza) UNCG, Dept. of Nursing and Dept. of Social Work UNCG, Dept. of Social Work WFU, Counseling Department Winston-Salem State University 31

The Need for Services: Child and Adolescent Mental Health Problems and Concerns 21% of children and adolescents in the U.S. meet diagnostic criteria for MH disorder with impaired functioning 16% of children and adolescents in the U.S. have impaired MH functioning and do not meet criteria for a MH disorder 13% of school-aged, and 10% of preschool children with typical functioning have parents with “concerns” 50% of adults in the U.S. diagnosed with MH disorders had symptoms by the age of 14 years 32

The Need for Services: Child and Adolescent Mental Health Problems and Concerns 33

Symptom Onset and Treatment Seeking Researchers supported by the National Institute of Mental Health (NIMH) have found that:  Half of all lifetime cases of mental illness begin by age 14;  Despite effective treatments, there are long delays — sometimes decades — between first onset of symptoms and when people seek and receive treatment; and  An untreated mental disorder can lead to a more severe, more difficult to treat illness, and to the development of co- occurring mental illnesses. See Ronald Kessler, Ph.D., et.al., (2005). Archives of General Psychiatry, June 6 th Issue. 34

North Carolina Demographics 1.5 million public school student in North Carolina (includes Charter School students) One of the largest school systems in the country 180 thousand school personnel 115 school systems 35

Students with Mental Health Issues The chart below shows the number of students with a known diagnosis as reported by school nurses from the N.C. Annual Report of School Health Services. ElementaryMiddleHighTotal Mental Health Issues 5,1113,5304,03812, Mental Health Issues 6,5825,9888,25920,829

NC Students with Known Suicide Attempts and Deaths High 11-12High 12-13Middle 11-12Middle 12-13Elem 11-12Elem Suicide attempts by grade level Deaths from suicide Deaths from homicide

SCHOOL HEALTH ALLIANCE FOR FORSYTH COUNTY OFFICE PHONE: (TRACY BRADSHAW, PRACTICE MANAGER) STEPHANIE DANIEL, PH.D. EXECUTIVE DIRECTOR OFFICE PHONE: Questions and Contact Information 38