School Based Health Centers: A Unique Service System Andrea Kuebbeler, LCSW Alternatives, Inc. IL Children’s Mental Health Partnership School Mental Health Conference June 27, 2012 Andrea Kuebbeler, LCSW Alternatives, Inc. akuebbeler@alternativesyouth.org

Objectives Overview of School Based Health Center’s (SBHC) How do they benefit students, parents, school and the community How are behavioral health services integrated into this model of service in schools

Many of the most significant and costly national health problems are caused by behaviors established during adolescence: Drug and alcohol abuse Tobacco use High-risk sexual behaviors Inadequate physical activity Poor dietary habits

What are School Health Centers? School‑based health centers, located on school grounds. School‑linked health centers, located off school grounds close to a school.

59 SHCs across Illinois Nationally the first SHC emerged in the late 1960s and early 1970s to respond to the high risk behavior of adolescents and to provide accessible, affordable primary health care and education to children and youth. Since that time centers have grown to more than 3000 across the county in 2000. In Illinois….. 47 serve low income districts Data sources: IDHS FY10 SHC Annual Report; ISBE FY10 eReport Card

29 SHCs in Chicago

Common Characteristics Located in schools or on school grounds Common Characteristics Located in schools or on school grounds. Work cooperatively within the school to become an integral part of the school. Provide a comprehensive range of services that meet the specific physical and behavioral health needs of the young people in the community. Employ a multidisciplinary team of providers to care for the students: nurse practitioners, registered nurses, physician assistants, social workers, physicians, alcohol and drug counselors, and other health professionals.

Provide clinical services through a qualified health provider such as a hospital, health department, community health center or medical practice. Require parents to sign written consents for their children to receive the full scope of services provided at the SBHC. Have an advisory board consisting of community representatives, parents, youth, and family organizations, to provide planning and oversight.

Fundamental Principles of SBHC’s: 1. Supports the School 2 Fundamental Principles of SBHC’s: 1. Supports the School 2. Focuses on the Community 3. Focuses on the Student 4. Provides comprehensive care 5. Advances health promotion activities

6. Implements effective systems 7 6. Implements effective systems 7. Provides leadership in adolescent and child health

SBHC Benefits Student: Provides medical, mental health, dental and health education services. Provides confidential, culturally sensitive and youth friendly services. Promotes health decision-making. Helps students stay in school.

SBHC Benefits Parents: Provides services their children need such as mental health, health education and treatment for acute and chronic diseases. Reduces lost work time. Promotes parental engagement in health care. Provides family assistance for benefits enrollment and other supportive services such as state health insurance programs, food stamps and Special Supplemental Nutrition Program for Women, Infants and Children (WIC).

SBHC Benefits School: Integrates health and education to address barriers to learning and promote academic success. Collaborates with school personnel to ensure that students are healthy and ready to learn. Participates in the school’s crisis intervention team to provide assistance in times of school crises and community disasters. Promotes health behaviors throughout the school.

SBHC Benefits Community: Links the students and families to community resources. Engages the community in health promotion activities. Respects family values and diversity within the community. Involves the community in improving the health of students and families

Staffing Recommended SBHC Staffing is: Medical Director Nurse Practitioner or Physician Assistant Clinically-trained Mental Health Practitioner Health Educator Medical Receptionist/Other Support Staff

The Need for Behavioral Health Services Around 20% of youth present with an emotional/ behavioral disorder Around 10% of youth experience significant impairment Less than 50% receive adequate or any services Over 75% of youth who receive services, receive them in schools

SBHC Behavioral Health Services Goal/Approach: Comprehensive, interdisciplinary and integrated Partnership based Full range of primary and secondary prevention, early intervention, and treatment services

Mental Health and Academic Outcomes Health & Mental Health Factors Academic Outcomes Educational Behaviors Physical Health/illness Mental Health Mental Health Problems High-risk Behaviors (e.g. Substance use ) Developmental issues Social Competence/Self- esteem Family Strengths/ Issues Attendance Behavioral Competencies Behavioral Problems Educational Motivation Positive Attitudes Toward Schoolwork School Connectedness Graduation/Drop-out Grades Standardized Test Scores Teacher Retention REFER TO HANDOUT Let’s now spend a few minutes discussing the critical link between school mental health and academic outcomes. School mental health plays a critical role in directly addressing both the health and mental health factors and the education behaviors represented in the diagram. Following from both of these are the academic outcomes we are ultimately attempting to impact as well. The connection to academic outcomes is complex yet important to understand as this is what will ultimately “make the case” for mental health in schools. This graphic attempts to explain this relationship. In the lower left-hand corner we see that SMH services can have a direct impact on a number of health and mental health factors (orange arrow) such as family issues or certain high risk behaviors…. SMH can also have direct impact on certain educational behaviors (dark blue arrow) such as school connectedness, attitudes toward schoolwork, or attendance (often referred to in schools as “seat time”). Finally we know that educational behaviors connect directly to educational outcomes, such as graduation rates and even test scores. So, while we’d like to say that if Maria comes in for counseling that her grades will automatically go up. Or that when a school forms a partnership with CMH program, that the graduation rate will go up. While we can’t say this definitively, we can say that if Maria is feeling depressed by problems at home and receives the necessary services that she will likely begin to feel better, be less distracted in class, and feel more motivated to do school work. While it is likely that her grades will also go up, we cannot demonstrate that that a specific MH intervention was directly responsible for that. Therefore, we can say that SMH has an indirect, rather than a causal, relationship to academic outcomes. SMH stakeholders can help schools face increasing attention to improving academic outcomes...SMH stakeholders must be articulate in conveying how their programs support the mission of schools. (see SMH messaging documemt) SMH ADAPTED FROM: Geierstanger, S. P., & Amaral, G. (2004). School-Based Health Centers and Academic Performance: What is the Intersection? April 2004 Meeting Proceedings. White Paper. Washington, D.C.: National Assembly on School-Based Health Care.

SBHC Behavioral Health Staffing Models SBHC hires on-site behavioral health staff. SBHC partners with local behavioral health agency. SBHC partners with school to collaborate with school social workers and other behavioral health staff because of lack of ability to hire on-site SBHC staff.

Benefits to Provision of Behavioral Health Services in SBHC’s Access: Reduction in Stigma Services immediately accessible at school Low or no cost for services

Benefits to Provision of Behavioral Health Services in SBHC’s Efficiency: Access to teachers in child’s life Ability to work collaboratively with system Screening more prevalent when primary care and behavioral health working together in same space

Benefits to Provision of Behavioral Health Services in SBHC’s Effectiveness: Services able to be more immediate as providers can work and observe youth in their natural environment Improve prevention and early intervention efforts in the school by behavioral health staff serving as consultants to school staff

Services Available Screening Assessment Case Management Crisis Intervention Individual, Group and Family Therapy Tobacco Use Counseling Substance Abuse Counseling Referrals Classroom Interventions Skill Building Conflict Resolution/Mediation Psycho-education Mediation Management/Administration Consultation

Referral Sources Health Center Staff School Administrators Teachers Self Referral Parent/Friend Community/Legal

Interconnected Systems Framework for School Mental Health Tier I: Universal/Prevention for All Coordinated Systems, Data, Practices for Promoting Healthy Social and Emotional Development for ALL Students School Improvement team gives priority to social and emotional health Mental Health skill development for students, staff, families and communities Social Emotional Learning curricula for all students Safe & caring learning environments Partnerships between school, home and the community Decision making framework used to guide and implement best practices that consider unique strengths and challenges of each school community Tier 2: Early Intervention for Some Coordinated Systems for Early Detection, Identification, and Response to Mental Health Concerns Systems Planning Team identified to coordinate referral process, decision rules and progress monitor impact of intervention Array of services available Communication system for staff, families and community Early identification of students who may be at risk for mental health concerns due to specific risk factors Skill-building at the individual and groups level as well as support groups Staff and Family training to support skill development across settings Tier 3: Intensive Interventions for Few Individual Student and Family Supports Systems Planning team coordinates decision rules/referrals for this level of service and progress monitors Individual team developed to support each student Individual plans may have array of interventions/services Plans can range from one to multiple life domains System in place for each team to monitor student progress Adapted from the ICMHP Interconnected Systems Model for School Mental Health, which was originally adapted from Minnesota Children’s Mental Health Task Force, Minnesota Framework for a Coordinated System to Promote Mental Health in Minnesota; center for Mental Health in Schools, Interconnected Systems for Meeting the Needs of All Youngsters.

Tier 1-Universal/Prevention for All Coordinated systems for promoting healthy social and emotional development SEL curricula for all students Safe and Caring Environments Partnerships with school, home and community

SBHC Services: Tier 1-Universal/Prevention for All Classroom Education Classroom Observation/Teacher Support Student Health Club Peer Health Education Campaigns

Tier 2-Early Intervention For Some Early Detection/Identification Short Term/Targeted Interventions School Coordination for Referrals Skill Building Staff and Family Training

SBHC Services: Tier 2-Early Intervention For Some Pull Out Groups: -Psychoeducational groups -Skill building groups Individual Skill Building Parent Support Groups/Skill Building Groups SBHC Staff Participation in School Behavioral Teams

Tier 3-Intensive Interventions for Few For Greatest Level of Need Individual Student and Family Supports School Team Identified to Support Student Individual Plan for Interventions

SBHC Services: Tier 3-Intensive Interventions for Few Individual, family and group treatment Substance Abuse Assessment and Treatment Psychiatric Evaluation and Medication Monitoring

Models of Behavioral Health Work Cognitive Behavioral Therapy (CBT) Trauma-Focused CBT Adolescent Community Reinforcement Approach (A-CRA) for substance using behavior Group Work Models: -Think First -Cognitive Behavioral Intervention for Trauma in Schools (CBITS)

Problem Areas Depression Trauma related issues Substance Abuse Family conflict School Problems Peer Conflict Anxiety

Challenges School Schedule Funding Space Change in School Administration Crisis work vs. longer term work

Private Foundations State of Illinois Funding Medicaid Billing

Questions?

For more SBHC information Illinois Coalition for School Health Centers 312-491-8161, www.ilmaternal.org, icshc@ilmaternal.org National Assembly on School-Based Health Care www.nasbhc.org, info@nasbhc.org Illinois Department of Human Services, Victoria Jackson, School Health Consultant, 217-785-5368, victoria.jackson@illinois.gov

Additional Resources Center of School Mental Health http://csmh.umaryland.edu School Mental Health Connection www.schoolmentalhealth.org Center for Health & Health Care in Schools www.healthinschools.org UCLA Center for Mental Health in Schools www.smhp.psych.ucla.edu

Presenter: Andrea Kuebbeler, LCSW Alternatives, Inc. 4730 N Presenter: Andrea Kuebbeler, LCSW Alternatives, Inc. 4730 N. Sheridan Rd. Chicago, IL 60640 akuebbeler@alternativesyouth.org 773-506-7474