Seattle SBHCs “Reaching for Excellence” TJ Cosgrove – Public Health Seattle & King County

Seattle’s School-Based Health Centers  14 SBHCs:10 Comprehensive HS 4 Comprehensive MS  Public Health-Seattle & King County serves as program manager  Four additional health care organizations serve as SBHC “sponsors”  School District and City are key partners

Seattle’s School-Based Health Centers  Staffing:1.0 FTE Mid-Level Practitioner (ARNP) 1.0 FTE MH Counselor 1.0 FTE Administrative Support  Middle schools flex.5 FTE ARNP into mental health and/or health education  Some sites offer “enhanced” services (health education, nutrition, massage therapy)

Seattle’s School-Based Health Centers Funding  Seattle’s Families and Education Levy  Partner Contribution  Billing (Medicaid, Take Charge)  National Philanthropic Organizations  Local Philanthropic Organizations  School District “in-kind”

Mental Health Services Prior to Caring for Kids Grant  SBHCs in transition from gateway to mental health services to provider of mental health services  Health care sponsors providing mental health services rather than subcontracting with community agencies  Reduction in resources for Medicaid eligible youth  Need to increase in-house skills, resources, and expertise to address the above trends

“Reaching for Excellence” Goals of the Project  Increase School-Based Health Center staffs’ ability to knowledgeably treat youth that have significant mental health issues  Improve interdisciplinary (mental health/physical health) coordination within the School-Based Health Center sites  Improve coordination with external agencies that provide psychiatric/mental health services

RFE Project Activities  Partnership with University of Washington / Children’s Hospital & Regional Medical Center Department of Child and Adolescent Psychiatry and Behavioral Sciences  4 second-year fellows to provide psychiatric support and services  1 University faculty member to serve as project lead  Formal trainings for all SBHC staff  7 sites to receive 4 hours per month of on-site psychiatric support, includes phone/ consultation  Evaluation and Communication teams

On-Site Psychiatric Support  Consultation to SBHC mental health and medical staff  Direct patient care: evaluation, pharmaceutical management, and referral  Formal training of SBHC staff  Program planning and evaluation

Evaluation Plan  Surveys of clinic staff (including school nurses) and psychiatrists each spring for the first three years of the project  First year evaluation also included structured facilitated group interviews with clinic staff at each school and the psychiatrists  Year 2 and 3 surveys repeated some questions to monitor progress on program development issues and added new questions to target impact of formative changes made based on earlier surveys  Data review and analysis

Using Caring for Kids Data to Inform the Program and the Project  Encounter forms were not collecting meaningful data  Procedure and diagnosis coding included: CPT, DSM-IV, ICD-9, and “homegrown” codes – without consistent definitions  Encounter forms were revised along CPT and DSM definitions/guidelines (with exceptions)  Training was provided by UW fellows and faculty on use and application of DSM-IV and diagnosis of externalizing and internalizing disorders  On-site services emphasized interdisciplinary consultations

Program Improvements & Lessons Learned  More consistent, reliable and meaningful program data  For example: In the last quarter (Oct-Dec) of 2004, 40% of mental health visits had “No Diagnosis” as the primary diagnosis. In the last quarter of 2005, 6.5% of mental health visits had “No Diagnosis” as the primary diagnosis  Improved data revealed prevalence of emotional health diagnoses leading to University-led training in CBT and IPT

Program Improvements & Lessons Learned Based on the surveys, the model for providing psychiatric support evolved toward consultation, particularly interdisciplinary case consultations. QuestionYear 1Year 2Year 3 Percent who felt amount of time psychiatrist spent on-site was adequate 27%53%80% Percent who worked with the psychiatrist in  Interdisciplinary Case Consultation  Assessment  Medication Management  Referrals 79% 63% 42% 16% 70% 45% 35% 20% 93% 27% 60% 47% Percent who saw improvements in medication management Not asked 45%80% Percent who saw improvements in interdisciplinary consultation process Not asked 50%60%

Program Improvements & Lessons Learned  As psychiatrist time was used more for consultation, staff became more satisfied with 4 hours per month  93% of staff believed having on-site psychiatrist created more opportunities for interdisciplinary consultations and 87% felt the psychiatrist improved the quality of these consultations.  73% believed that the on-site psychiatric support was the aspect of Reaching for Excellence that contributed most toward improving mental health services

Program Improvements & Lessons Learned  The picture that emerges is a steadily improving multidisciplinary approach to provide mental health services that maximizes the benefit of a small amount of psychiatrist time  Over the course of the project, improved data, enhanced skill sets, and a partnership with University expertise formulate professional development needs

Sustaining the Project  Continue each of the four fellows providing consultation and service to two school-based health centers  Each rotation includes two sites that are geographically proximate and, when possible, the pairing has included a high school and a middle school that “feeds” into the high school  SBHC sponsors will reallocate a portion of contract dollars from SBHCs into a contract with the to maintain these personnel and this model