Summary of Annual Meeting

Expanding Mental And Dental Health Services
within School-Based Health Centers:
Operations and Evaluation Challenges

Summary

The Caring for Kids initiative funded by The Robert Wood Johnson Foundation is supporting the development of several models for expanding mental and dental health services within school-based health centers. A primary objective of the grant program is to describe the process by which these models are put in place and assess their strengths and weaknesses. This edited transcript describes the operations and evaluation challenges that the grantees have experienced or anticipate and summarizes remarks by school-based health center research and evaluation expert, Dr. Linda Juszczak.

Grantees developing mental health initiatives report that their greatest operational challenges include: securing and sustaining support for organizational change, blending mental health disciplines, and defining the relationship between the health center’s mental health providers and the school’s academic program. Program evaluation issues include defining who is a mental health provider and what is a mental health encounter and determining if a program evaluation can measure whether the new service improves students’ mental health status. Summary tables are found on pages 10 and 16.

Grantees developing dental health initiatives report their major challenges as: integrating children’s dental issues into the medical staff’s physical assessments, overcoming community and parent disinterest in the importance of dental health, and connecting dental services with disease prevention/health promotion initiatives in nutrition, tobacco use, and injury prevention. Evaluation questions to be addressed include: Who do we serve? Do we improve access? Are we improving community or parent understanding that sealants and dental care generally are important?

Introduction

In June 2002, the 15 grantees of The Robert Wood Johnson Foundation Caring for Kids (CFK) Initiative met in Denver, Colorado to discuss the challenges and opportunities they are confronting in launching new mental health and dental health programs within school-based health centers.

While some of the challenges were similar for both groups, how to collaborate with colleagues from different disciplines, for example, others were unique. While mental health programs wrestle with definitional issues in the design of data-gathering systems, dental programs struggle to decide whether they need two consent forms or one to provide preventive and restorative services. Dental programs also felt uniquely challenged in engaging parents in caring for their children’s dental needs.

This discussion reflects grantees’ experiences from their first six months of participation in Caring for Kids.

Project Evaluation: An Overview

Linda Juszczak, DNSc, MPH, CPNP, Director of the National Assembly’s Center for Evaluation and Quality at Montefiore Medical Center, led off discussions of research, evaluation, and quality improvement and with an overview of basic issues. The following comments summarize Dr. Juszczak’s remarks on program evaluation.

The goal of most evaluations is to provide “useful feedback” to a variety of audiences including sponsors, donors, client groups, administrators, staff and other relevant constituencies. Since their earliest days, school-based health centers have attempted to document their effectiveness. Project evaluation efforts by the Caring for Kids grantees will be particularly important because relatively few published evaluation studies have focused on mental health services organized by school-based health centers and even fewer have evaluated the impacts of dental programs organized by the centers.

To assist in planning an evaluation of CFK-funded projects, Dr. Juszczak emphasized evaluation basics to be kept in mind:

* The difference between what we might want to measure and what we can measure. In most evaluation work associated with school-based health centers, evaluation thinking has run something as follows:

What we want to measure:

  • Wellness
  • Holistic health
  • Lives saved
  • Life success
  • Cost efficacy  What we can measure:
  • Enrollment/visits
  • Who uses services, how much they use and if they use more or less than other sites
  • Bad behaviors
  • Success in advancing a grade
  • Effects of short-term interventions on small groups of students

To get the evaluation job done, we sometimes have to settle for the do-able as opposed to the most fundamental questions that we would like to wrestle with.

  • The importance of defining project goals that are to be evaluated. There are multiple possibilities: improving access to certain services; achieving certain outcomes; or demonstrating an improvement in quality of care. Be clear about the questions you will answer in your evaluation.
  • After the evaluation question or questions are selected, the study design, including the data elements required and the methods to be used to collect the data, can be developed.
  • Other important tasks include: assessing the resources available to the project – money, time, and expertise, and establishing a timeline, and determining how the study’s findings will be used to inform both the school-based health center’s practice and the policies that impact its programs.

Data sources commonly include: management information systems, standardized data collection instruments, surveys, interviews, and focus groups.

Examples of evaluation indicators often associated with school-based health centers are the following:

  • Percent of students screened for: general health, reproductive health, nutrition problems, violence and injury risk, pregnancy and STI risk factors, sexual abuse, mental health or behavioral health problems, school performance, family dysfunction, and dental health.
  • Percent of students receiving; general physical exams; dental exams/sealants, restorations; immunizations; STI testing; annual pap smears and pelvic exams, and mental health services.

There are many challenges associated with the definitional work that needs to be done before evaluation studies can be put in place. What constitutes a service? Who is a mental health provider? What are the definitions for assessment, evaluation or treatment? Are you going to track all services or just look at a particular type – individual, group, family? Do you want to look at service coordination? If you are looking at outcomes, how do you approach the dose/response issue, ie. how much of what for how long?

There may be specific mental health outcomes you want to examine. These could include:

  • High parent satisfaction
  • Students with behavioral issues can demonstrate self-care skills
  • Patient perception that well-being has improved
  • Increased compliance rates as measured by follow-up visits completed, prescriptions filled, therapy attended, referrals completed, etc.

Dr. Juszczak concluded with two main recommendations for developing successful evaluation studies. First, to be successful, staff must buy-into the notion that the school-based program is accountable to its patients. their families, funders, and stakeholders for progress on stated program goals. The evaluation can serve as a vehicle for reporting back to these critical audiences. Second, successful evaluations involve staff in their development as well as implementation. Staff buy-in, essential to data collection on which evaluation depends, requires not only staff support but staff insights and contribution to evaluation design.

While evaluation research conducted within school-based health centers has particular advantages — access to a convenient population, a well-defined intervention, the availability of related data from the school system and perhaps other sources — there are substantial challenges as well. These include those listed below.

Challenges in Conducting SBHC Evaluations

Implementation issues

  • Difficulties in attaining pre-intervention data
  • Tremendous variability in the SBHC model
  • Political/administrative hurdles to implementing evaluation
  • Researcher/evaluator bias
  • Written parental consent

Research design challenges

  • Small sample sizes
  • Difficulty getting appropriate comparison groups
  • Self-selection in enrollment in SBHC and use of SBHC
  • Prevalence of problems being studied, eg. at-risk of asthma vs. at-risk of suicide
  • Shifting denominators due to transfers, dropouts, “stop”outs
  • Shifting numerators due to fluctuating daily attendance

Juszczak, June 2002

Other challenges may impede the evaluation. While health centers generally try to identify if students are receiving services in the community, not all centers have good data on the role of community-based providers. Similarly while staff will likely be aware of major developments within the school and community that may confound intervention effects, this is an area of uncertainty. School-based health center staffers may also find the data demands of the evaluation too burdensome for full compliance. Time commitments — especially those caused by additional data collection — and technology issues may also impede the evaluation.

Obviously, these are reasons why evaluation plans are not always converted to evaluation reality. But the hard truth is that funders, whether public or private, have become increasingly sophisticated in their understanding of research and what constitutes an acceptable level of evaluation research. We really have no choice. We will need to find ways to evaluate what we do with credibility and timeliness.

Mental Health Challenges

The eight participants in Caring for Kids initiative that are developing mental health interventions met in two workshops to discuss their projects and exchange views on operational and evaluation challenges.

Project plans

Lynn Community Health Center (Lynn, MA). Lili Silva, Director, School-Based Health Centers. The Lynn Community Health Center operates eight school-based health centers. All our centers have a mental health provider who is on site about 20 hours a week. Our proposal looks to expand our services by bringing on a psychiatric nurse specialist and a pediatric psychiatrist to help us address the issue of medication management. We also plan to provide consultation services and support to the mental health providers in the other school-based health centers. The psychiatric nurse specialist will be based at one of our new school-based health centers that opened this past year. She will be the primary behavioral health provider at that site as well as a consultant to providers at the other seven centers. Her job will be to see what issues come up in medication assessment and medication management. Our goals are to do a better job of staying in touch with our students, providing continuity of care, but not contributing to duplication of services.

Buncombe County Health Center (Asheville, NC). Nelle Gregory, School Health Supervisor, Buncombe County Health Department. The Buncombe County Health Center, a part of the Buncombe County Health Department, sponsors three school-based health centers — two urban and one rural. We will expand mental health services in the centers by hiring two licensed clinical social workers to join the one licensed clinical social worker (LCSW) who currently serves the three centers. In the long run, we hope to partially fund the mental health program with Medicaid and NC-CHIP money. In North Carolina we can receive Medicaid and NC-CHIP funding for up to six mental health visits that do not have mental health (DSM-IV) diagnoses. Thus we can use v-codes for these initial visits. We hope to do in-depth evaluation of the v-codes we see on those first six visits.

University of New Mexico Center for Health Promotion and Disease Prevention (Albuquerque, NM). Nissa Patterson, Health Education Manager, ACL Teen Centers.

This grant, along with another, will support a master’s level mental health professional 30 hours a week at our two ACL Teen Centers. Our focus is on catching and helping kids before they’re really in trouble. Pediatric and psychology interns will also participate in this phase of our work. The project psychiatrist will provide consultation to staff on-site one day a week. Because this is a rural site, we also want to increase the capacity of community providers. Therefore, the project psychiatrist will provide quarterly in-service sessions for staff and community providers together. We also plan to increase our capacity and effectiveness in intervening on substance abuse by training staff and community providers in substance abuse interventions developed at the UNM Center on Alcoholism, Substance Abuse, and Addiction (CASAA).

Seattle-King County Public Health (Seattle, WA). Linda St. Clair, Manager, Youth Health Services, Seattle-King County Department of Public Health. We manage a system of 13 school-based health centers in Seattle Public Schools. All our school-based health centers currently have mental health counselors. This grant enables us to add psychiatric fellows from the University of Washington to provide consultation on site to staff at seven of the centers. On a limited basis the fellows will also provide direct care to students referred to them.

Children’s Hospital of Los Angeles(CHLA) (Los Angeles, CA). TuLynn Smylie, Director, School-Based Health Program, CHLA. Children’s Hospital sponsors three school-based health centers in LA High, Hollywood High and Manual Arts High School. Our challenge is to figure out how to sustain mental health services. We have provided mental health care on and off through the years but nailing down the funding has eluded us. With this grant we are expanding services by reviving a program of psychology interns. A new project coordinator will enable us to document performance improvement and outcomes. We will also focus on maximizing third-party revenues by employing a part-time bilingual enrollment specialist to facilitate utilization of Medi-Cal and EPSDT funding.

Children’s Aid Society (New York, NY). Scott Bloom, Director, Mental Health, School-Based Health Clinics, Children’s Aid Society. Children’s Aid Society has five comprehensive school-based health centers, ten dental clinics, and a number of mental health clinics in schools that do not offer comprehensive services. Our grant will do a number of things. We want to expand services, particularly at one of our schools, IS-218, which has more than 1,700 kids. We will do this by hiring a Senior Social Worker. We also added another staff social worker, so now we have three staff social workers plus the senior social worker. In addition to increasing capacity, we want to sharpen diagnosis and treatment approaches. We will use the computerized Diagnostic Interview Schedule for Children (DISC) tool to identify children with problems. We also plan more outreach to teachers, especially to do training around appropriate referrals. And we will do workshops with parents on adolescent development, how to talk with your teens, etc. Our plate is pretty full.

Schneider Children’s Hospital, North Shore-LIJ Health System (New York, NY). Martha Arden, Director, School-Based Health Services, Schneider Children’s Hospital. Schneider Children’s Hospital sponsors three urban school-based health centers: two are high schools and one is a middle school. With the grant we will expand and reorganize the mental health program at the school-based health center at Franklin Lane High School. 3400 students attend this school and 90% of them are enrolled in our clinic. Our current mental health program includes a social worker supervisor and a staff social worker, as well as another staff social worker and program coordinator funded by a sexual abstinence support grant. With CFK funding, we will institute standardized assessments and treatment planning conferences in order to assign patients to mental health services in a structured fashion, distinguishing those who would respond to social and emotional support from those who have diagnosable mental illness. Support will be provided in a group format, while individual therapy will be provided using evidence-based, outcome-oriented therapy methods. A psychologist will be added to our mental health team, providing expertise in these treatment methods and making our program eligible to bill for Medicaid for mental health services, as social work visits do not qualify for reimbursement in NewYork State. Social work graduate students will increase our program capacity by administering computerized assessments, assisting with groups, and helping families obtain insurance coverage.

Dorchester County Health Department, (Cambridge, MD). Kathleen Wise, Program Manager, Healthy Families, Dorchester County Health Department. Dorchester County, Maryland’s largest county at low-tide, has four school-based health centers sponsored by the Health Department. We are using some of our grant to hire an additional social worker so that we now have four licensed clinical social workers (LCSW) at the two high school and two middle school health centers. Three additional LCSWs provide care at the elementary schools. In Maryland, LCSWs are reimbursed by Medicaid IF there is a DSM-IV diagnosis. We will use the grant period to explore the possibility of billing for commercial insurance payments for these services as well. We plan to secure psychiatric consultation not only to work with the staff but also to see children for medication evaluation. Finally, it is our hope to secure some intra-office coordination with the Health Departments addictions program so that we might bring some of their services into the schools.

Operational Issues

Bruce Guernsey, group facilitator. As a person trained in clinical social work, one of the reasons I left personal health care and went into public health was that I was looking for a more holistic, interdisciplinary approach to health. But I didn’t find what I was looking for in public health either. In our state, when it comes to health services, public health is nursing-dominated just as personal health care is physician-dominated. So, I kept looking. And I stumbled into school-based health centers. And while the people I met in the field initially saw school-based health centers as a promising means to address teen pregnancy, the first thing that dawned on me was, this is a promising way to deliver mental health care and I got very excited.

What this session is about are the operational issues confronting your programs. Where do you want to end up in three years? And what do you need to do now to make sure that is accomplished?

Issue 1. Introducing change: How do we gather support for what’s new?

Scott Bloom, Children’s Aid Society: In our Caring for Kids project, we are adding new structures and procedures to more clearly identify who needs services and to make sure we match a student’s need to the most appropriate type of care. We are going to use new in-take forms and use more time-limited therapies. And I can see it will be difficult to make that transition because our staff members are used to the earlier, “looser” way. So our question is: Since we’ve been in operation for awhile, how do we get people comfortable with and accepting of these new procedures?

And the changes affect not just our staff. They affect student users, teachers who refer to us, and the community-based providers to whom we refer.

The role of vision and mission

Guernsey: This may be where vision and mission fit in. Maybe this is when people need to get together and articulate what the changes will be and try to develop buy-in.

Beverly Colon, Children’s Aid Society: Our program is doing a Retreat Day before school begins. We are going to use the summer to get our staff on the same page. We hope that when September gets here, we can then take the program to the next level. This should work well for us because our whole school-based health center has a couple of days before school when no one can take leave and we all — medical, dental, mental health — the whole team comes together, puts on t-shirts, and has a full-scale retreat.

Our task is to get everyone — both in the mental health team and in the health center at large — used to the fact that we are no longer going to be unstructured. It used to be that referrals came in without anything written down. We need to make sure that the right response is developed. We have peer mediation. I like peer mediation but I need to know that it is right for a specific kid in a specific situation. But however this plays out, we have to create boundaries and structures in the school. We cannot continue with our current pattern which is that the social workers believe they must do whatever the teacher asks.

Guernsey: So the retreat will be an opportunity to define vision and mission and introduce changes in policies and procedures. And it will help you articulate yourselves to the broader school community

Challenges and Responses in SBHC Mental Health Service Development

Accustoming staff to new structures and procedures

  • Use staff retreats to get all members on same page
  • Develop marketing plan for SBHC to explain and promote new arrangements
  • Introduce mental health program or program changes at back-to-school faculty meetings, with more extended discussion to follow at breakfast or lunch meetings at the center
  • Plan informational activities with the school population as a whole; provide feedback on new activities or changes to school staff

Developing a cross-disciplinary mental health practice

  • Develop a SBHC program report card to share service and other data with staff
  • Work to develop a team practice with a vision and mission statement that is backed up with policies and procedures

Defining the roles of medical professionals in providing mental health services

  • Formalize the case conferencing process with regularly scheduled meetings and agendas. Include mental health and medical staff together.
  • Clarify roles and responsibilities of all staff

Building relationships with parent organization

Participants agreed this topic included major challenges that were not always under their control, whose solutions were not readily apparent. Thus this topic remains just that – challenges to be addressed with responses to be developed as the programs mature.

  • Challenge of building a positive relationship and figuring out how to address specific issues inherent in small program/large institution dynamics
  • Challenge of sponsoring organization moving to paperless record. How do you make sure that new record is usable at the school-based site?

Using Strategic Communication Tools

Unknown: One of the things that has helped us is that we took advantage of The Robert Wood Johnson Foundation offer for strategic communications training. That training was very useful in thinking about these issues — communicating strategically with teachers, community providers, our sponsoring institution, etc. The training has helped us stop and say, “Where are our target audiences? What do we want them to know? What do we want them to do?” So we’ve created a communication action team that is going to help develop messages and think about how they get delivered.

Guernsey: How we deliver these messages really matters. Even if the basic words are “You’ve been a great faculty and staff and we really appreciate your connecting us with students. We have some plans to make it work even better.” But you know not every group will bite or bite as quickly on this message. What are you doing that works?

Mona Carey, Dorchester County: We feed them. We invite people for lunch. We invite teachers for lunch. We invite other agencies for lunch. Space is always a problem but we make it work because we have to. Sitting down and breaking bread together seems to mean we can talk about some of these things in a non-threatening way.

Guernsey: One lesson from my experience is that lunches are good places for discussion and negotiation; the annual faculty meeting at the first of the school year is not. The back-to-school meeting is good to find out what is going on and what the school’s current concerns are. But it’s not a good time for extended conversation. The school has a lengthy agenda and our information can get lost or distorted.

Unknown: Sometimes there is an opportunity if your school does workshops for CEUs at the beginning of the school year. Then the school may want people who can teach those things. And the faculty members that come will be interested. But it is a difficult time of year to get people’s attention.

Colon: One thing we are doing this year is to invite faculty to our school-based health center retreat. We will let you know how it works out.

Unknown: We’re testing moving from the sound bite at the big meeting to a more extended discussion at the departmental meetings. At the middle and high school level the schools have departments and they have meeting times. They’re real intimate. Also the kinds of referrals you get from departments vary so this makes different conversations more helpful.

Maintaining Changes

Unknown: Another angle on this problem of introducing change is how to maintain it. I can see us doing real well in September and October and then beginning to backslide. How do you maintain momentum?

One thing I learned from past experiences in school is that that environment is used to seeing new initiatives come and go. The prevailing view is “This too shall pass.” So we should plan for backsliding to happen. Knowing it will occur, how do we re-energize our efforts periodically?

Guernsey: Would it be possible to provide feedback to the school on how the changes are going? Let faculty and staff know whether the new procedures are making a difference? Maybe some case studies or data on how many kids you’ve seen? How many faculty referrals have been handled? Some schools have e-mail and that may be a vehicle for providing feedback.

Julia Lear: One school-based health center I visited sent out a teacher thank-you that included a report and a small gift. I don’t remember whether they got donated movie tickets or some other gift, but they had something they could tie a ribbon around to accompany their report. It is so uncommon in the school setting for teachers to receive tangible appreciation that the small gesture meant a lot.

Unknown: One of the concepts we’ve used is to think about faculty and staff as one set of our mental health clients. Just as with our clients, we try to be aware of what is going on in their lives — the cycle of report cards, planning, the end of the year. Then we are in better shape to anticipate their needs and respond.

Colon: In our school, we surveyed both teachers and parents regarding topics they would like to hear about from us. When the Board of Education sets aside training days for teachers, we are able to participate and provide training on topics the teachers want.

Issue 2. Blending mental health disciplines

Martha Arden, LIJ-Northshore: We have a different kind of challenge. We are adding a psychologist to our mental health program that has historically been staffed by social workers. It may be quite difficult for those two disciplines to agree on how to describe mental health issues, how to approach therapy, and how to address a host of other professional issues. Developing a common language and common program will be a challenge. How do we create a workable, cross-disciplinary practice?

TJ Cosgrove, Seattle-King County, WA: Let me put an upside to that. In Seattle, we’re adding psychiatry to our clinical social work services. Everyone is thrilled and sees this as a win-win. Of course, the psychiatry consultation won’t be there on a daily basis. However, the psychiatrist does build a bridge between mental health and medicine for us.

Case-conferencing: A tool for bridging disciplines

Guernsey: What I’m also hearing is that how well cross-disciplinary mental health practice works may be a function of how you “team” it. Adding a new piece to an existing team may throw the old arrangements out-of-balance. How can a new balance be created?

While we’re talking about interdisciplinary practice, it seems that you’re saying that your case conferencing is done on a catch-as-catch-can basis. Why is this? What are the barriers to routine, scheduled case conferences?

Unknown: We’re a small staff; we find informal works for us.

Unknown: What I’ve found is that even in well functioning teams, people may talk less than they think.

TuLynn Smylie, Children’s Hospital of Los Angeles: We found that over time, case-conferencing became more systematized. As we got busier, we had to schedule talk time to make sure it happened. The longer you are open, the busier you get, the more you “move into your office” and the informal case conferencing is reduced.

Trainees are the other program element that pushes scheduling case conferences. At the LA Free Clinic where I spent time initially, there were trainees from all the disciplines. But part of everyone’s weekly business was a one-hour lunchtime case conference. I was sold then and I can’t imagine wanting to practice without that component. It just seems to strengthen everyone.

Guernsey: I’d have to second that. I find teams do less informal consultation than they think. I also think we believe we’re catching the important stuff and that may not be the case.

Smylie: But to make it happen, there has to be leadership from the top. What struck me was that the busiest people who were also teaching at Children’s Hospital thought this was important enough to come do.

Another benefit of the case conference was that for our highest risk patients who frequently were also the highest users more than one person was familiar with their case. When their regular provider was not at the health center, another person was somewhat familiar with the case. It really helped continuity.

A related question I’d like views on is the participation of non-clinical staff at case conferences. Sometimes we include the front-desk person because that person has knowledge and a caring relationship with certain students. But we want to make sure we have a clear view of what that person’s role is.

Unknown: We have a health educator but she does more population-focused activity and little individual counseling. She would not be included in a case review.

Unknown: We had help from health educators who are working individually, especially as part of HIV prevention work. They interview and meet with students. We would see them as appropriate participants with certain cases.

Unknown: My background is in youth development. I really think that the front-desk person is a youth worker. I think she is a valuable team member and I encourage the clinicians to integrate her more into their case discussions.

Guernsey: These issues sound like our biggest, most immediate challenge. You are all expanding. Your program will become different. How do you get your staff to behave differently? How do you get your referring sources to behave differently? How do you integrate a broader teaming that includes components that you did not have before.

Issue 3. Building relationships between the medical staff and mental health staff

Guernsey: How do mental health professionals react to the idea of a physician or nurse practitioner having some part in the mental health treatment plan?

Unknown: In our center, the nurse practitioner is so busy with medical stuff that I can’t imagine her handling much of the mental health piece. But she’s done a nice job of transitioning kids with whom she’s developed a relationship around their physical issues. Though some might say that successfully transitioning a young person from a physical problem to an understanding that they might benefit from counseling is a therapeutic function.

Unknown: One thing we noticed when we went from one social worker to two and thereby made someone available for crisis intervention, we saw the nurse practitioner’s medical visits increase. In think as we made resources more available to the medical side, they could hand-off those problems to us and, as a result, strengthening the mental health program strengthened medical services as well.

Cosgrove: The nurse practitioners in Washington State just got prescriptive authority. We are very curious about the communications among the medical providers who may be involved with patients around psychotropic drugs and the mental health professionals who may or may not know this is going on.

Guernsey: That brings us back to the discussion we had about how we handle this kind of issue on a team basis and how we assure that the mental health services are coordinated and support each other.

Unknown: A couple of ways to handle this come to mind. One approach would be to print out a list of kids who have been to the center 15 times. Maybe that number of visits is necessary but maybe an interdisciplinary plan might get the kid’s needs addressed more effectively.

Issue 4. Defining the relationship between the SBHC mental health providers and the school’s academic program

Kathleen Wise, Dorchester County: I would like to raise another issue: the relationship of mental health staff to academics. This business of interfacing with the academic environment and supporting students who are failing academically is not easy. Last year our school-based health centers had the experience of securing a small grant to develop a parent/child homework club. But the teachers and guidance counselors have not wanted to be involved in this project. So how far can we go in addressing academic issues that are key.

Let me add that the student who won the school’s “most improved student” award went from straight E’s to A’s and B’s as a result of his involvement with his mother in the homework plan.

Unknown: Even if you are not directly involved in providing academic support, what is our role in terms of advocating for students around the special education program? And how do we define our advocacy role?

Scott Bloom, Children’s Aid Society: That’s a big issue for us. We can become involved in Board of Education special education processes – filling out forms, participating in IEP conferences. And we get very frustrated when the school staff who are supposed to show up don’t show. We’re not used to that in the health care environment I come from. But we understand that re-organizing school services is not what we are supposed to do.

One of the Children’s Aid Society mental health professionals was speaking with an assistant principal and it turned out he thought our job was to be the link to the Special Education evaluation. It was a total misunderstanding.

Unknown: The model that is useful for me is to think of myself as a peak performance coach. My job is not to be the person pointing their finger and labeling people as unable to perform. And the coaching mindset is consistent with that of school personnel.

Issue 5. Negotiating the relationship between health-center based mental health professionals and school mental health professionals

Unknown: In our school, another challenge is the relationship with the school psychologists who primarily test students for placement in Special Education programs. Sometimes, under pressure from the school system, the school psychologist may say that a student doesn’t need special education when our clinicians can demonstrate the student does.

Wise: As a former school board member, one of the things I am always aware of is that education has to pay for kids that need special education services. It is no surprise that education is reluctant to put a lot of kids into special education.

We really need to recognize the school system’s needs and sometimes that may mean that we need to take longer to solve a problem if that’s what it takes to allow the school system to solve problems. For example, the tutoring problem that Mona mentioned. We could probably find a tutor more quickly than the school. But maybe we have to give them an opportunity to solve the problem or work with us to solve the problem.

Unknown: We also have to pick our battles. I’ve certainly had to balance kids’ needs against reality. One response is trying to coach parents to advocate for their children. When we get a parent involved and the parent responds to coaching, it is one of the best outcomes possible.

Issue 6. Maintaining patient confidentiality

Marco Martorano, LIJ-North Shore: There probably won’t be time to discuss this issue now but a major issue for us is patient confidentiality and helping school staff understand the limits of what we say. I’m not sure if HIPAA is going to make this job easier or harder.

Unknown: Our confidentiality problem is a little bit different. We have case managers who serve both the medical and mental health sides of the shop. They do a lot of triage. The mental health professionals sometimes have tensions with this position because they say the kid needs counseling or some kind of therapeutic relationship with a provider. The case managers say: this kid isn’t ready for that. He just needs someone to talk with about a breakup with a girlfriend or boyfriend. Could we develop some guidance around these positions that straddle mental health and case management?

Guernsey: So another question is: how do the counseling services provided by non-mental health trained providers figure into the overall mix? What do we need to do to make sure we know who is doing what pieces and that their practice is clinically sound.

Issue 7. Mental health billing and state financing policies

Guernsey: This is a big issue to leave to the end. It’s not easy. At the state level we have to get the Departments of Education and Health as well as Medicaid to decide how they are going to funnel some resources to support mental health services for kids.

With all your different approaches to providing mental health care, it will be up to you to document what you are doing and whether current reimbursement or other state funding is providing adequate support. The increasing support for mental health parity will certainly help.

Concluding Thoughts

Lear: What I have loved about this session is that we have been talking about how you can provide superb mental health services in a school-based clinic. That is the goal of this program. What you are doing and what you are concerned about is precisely what the whole school-based health center field needs to know. So keep doing what you are doing, please document, describe and share what you are learning. It will make a tremendous difference to the kids, their families, your colleagues, and the schools.

Guernsey: I agree with that completely. School-based health care is a simple idea that is extremely complex operationally. But from my experience, 100 percent worth the effort.

Evaluation Issues

With four of the eight mental health projects using the Clinical Fusion software package to collect data in their centers and the rest using other electronic management information systems, the basic information that will be required for management and research will be electronically stored and retrievable. The group focused its conversation on their collective need to define the core components of their services and to identify questions about their projects’ performance that would be helpful to study (see below).

Collecting Data and Evaluating Mental Health Services in School-Based Health Centers: Questions to Answer

Definitions needed

  • Who is a mental health user?
  • Who is a mental health provider?
  • What is a mental health visit?
  • Within a mental health visit, how do we categorize and count mental health services?

Outcomes

  • Are we improving mental health?
  • What do our students/clients think about our care?
  • Have we improved students’ access to mental health care, both on site and by referral?

Processes

  • How many students are being screened? How many are referred for services?
  • What treatment modalities are being used?
  • To what extent are school staff involved as measured by teacher consultations and teacher referrals/feedback?
  • To what extent is student academic risk assessed? (This might be measured by grade point average noted in medical record or by documented advocacy on behalf of student academic needs, eg seeking academic support or after-school program for student.)

The evaluation discussion reflected two concerns: (1) that we need to identify evaluation questions that will be asked by all sites, and (2) that we cannot identify evaluation questions until we resolve definitional issues fundamental to collecting common data elements. The conversation did not resolve the tension between these two points. The Program office will offer some suggestions during the 02 – 03 school year.

Linda Juszczak, facilitator: Here are some questions to think about. What kind of information or data do you want to gather? How do you need to collect it? What do you need to show? And to whom? Legislators? School officials? Parents? And how can we standardize our data or create commonalities among our data bases?

Marco Martorano: One of the questions we’ve discussed is how we define mental health users? Is this a person who uses a service provided by a mental health provider? Is it a person for whom a V-code is assigned. If a person is seen by a nurse practitioner who uses a V-code for the visit, does that person become a mental health user? Or, for purposes of data collection do you include only those visits provided by certified mental health providers?

Mona Carey: That’s a great question because our nurse practitioners say that they do a lot of what they consider mental health counseling. But they can’t bill; they can’t make a mental health diagnosis. So, there’s a large number of visits that would be considered mental health but we don’t track those codes.

Martorano: We bill everyone – “counseling, not otherwise specified”. And so the issue is you never actually know what the student’s being seen for. The issues around labeling or giving a formal diagnosis are big issues.

Juszczak: May I suggest we take advantage of the opportunity to determine what data will be tracked and used to evaluate the effectiveness of the program. Some of the questions the dental health group are considering may be relevant. The first one that they are tackling is are we improving dental health? The second question tries to get at the unique aspects of providing dental services in a comprehensive setting: What is different about being part of an integrated team? What is different about school-based dental care for providing care at the community health center down the street or at the dental school’s outpatient clinic?

Wise: It is difficult to talk about what we will evaluate before we are clear on what we value and what are the unanswered questions in relation to those values. This may be harder to do in mental health than in dental health.

One of the things I’m hearing is a question about use of V-codes, which identify mental health-related services as opposed to diagnoses, which define a mental health disorder. If we try to use billing data for evaluation, in Maryland we will only capture diagnosed mental illness because we can only bill for kids with a DSM-IV diagnosis. However, our program is also clear that we will not diagnose just to get paid. So we see a lot of kids for mental health-related services that are not diagnosed. What is the best way of describing that part of what we do and measuring its effect?

Juszczak: Good point. So create your own way to capture that information. Come up with a list of categories – don’t call them diagnoses – that you want to count.

Nelle Gregory: I like breaking categories into prevention, early intervention, and treatment. For us, we look at a public health model in which we emphasize prevention and early intervention.

Juszczak: Back up – why are you counting people? The question on the table is evaluation, not program reporting. What is the question you are trying to answer? Why are you counting them? To what end?

Scott Bloom: Picking up on Kathleen’s point of our need to explore basic issues before grappling with which ones apply to an evaluation structure, we probably don’t even agree on what mental health services are. I think that is one of the questions we are struggling with. What is an intervention as opposed to treatment, and how do you define the difference? Where does risk assessment fit in.

Juszczak: You’re right! Evaluation may be tougher in mental health than in dental. At least a cavity is a cavity.

Lili Silva: In terms of the relationship of mental health services to our centers’ medical component, we need to look at the number of kids we screen and how many are referred.

Juszczak: Is that something you want to look at? Your relationship to the other providers? All your programs are providing mental health care in the context of a multi-faceted, school-based program.

Bloom: Our goal is to screen the entire student population so that we can do early intervention. Until then, we just try to take advantage of all our encounters to assess the students for mental health problems.

Juszczak: So to pull this conversation back toward evaluation & evaluation design, a basic question could be: What are we doing? To make the design more complex, the question could be: What are we doing compared to what other people are doing? This latter question should be achievable. Are there other places you can get the data? Maybe in your sponsoring institution also manages an outpatient clinic or a community-based program? Could you get information on how often teenagers or younger children access mental health services at the other facilities?

Arden: If we took your original question and plugged in the word “mental” instead of dental, then the question is: are we improving mental health? That is what the funders want to know. They don’t really hear the prevention or early intervention distinctions. Their point is: If we are funding you to provide care in schools, are you improving mental health? That is a very difficult question to answer. You may not know if you are improving mental health for 10 to 20 years. The studies that answer that question are longitudinal studies.

Juszczak: Good point. But that brings us back to the question: what data do you want to collect now?

Colon: Marti’s right. Outcomes are long term. We’re looking at access. Without our services, would our kids get mental health services? What students do access those services and who doesn’t? And what do we know about the kids who don’t come in. For elementary school programs we might be more ambitious because you can track those kids into high school.

Unknown: You need an operational definition of access. It’s more than just counting the students you see once. We are heavily engaged with our kids and we can do more than identify the problems. We are involved in their treatment as well. We can use chart reviews to document this 2nd part of our impact on access.

Unknown: Another aspect of expanding and enhancing services is raising the knowledge and skill level of the staff. We want to improve referrals — both to school-based clinic providers and to community providers. We’re also concerned about consumer satisfaction. And we should include the families in measuring that satisfaction.

Unknown: We’ve been involved in a study at our site, comparing routine therapies for depression. The problem with effectiveness research is that this kind of research requires Institutional Review Board approvals (IRB) and, basically, elaborate staff-intensive procedures. We need to keep in mind the resources required to pursue the evaluations we propose.

Juszczak: It might be helpful to remember there are things that you may want to tackle at your individual sites, but what we are talking about right now is what is the aggregate data we want to collect across all sites. And in order to determine what that is, you have to know WHY you want to collect them.

Unknown: Even describing what we do is tough. We need to ask what treatment modalities are being used? How much group work are we doing? How much are we working with individuals? How much are we working with families? I think it would be a tremendous contribution to the field to have this many programs provide information about how you operate and what you do.

Unknown: I’m particularly interested in educational outcomes and in the relationship between the mental health staff and school personnel. What kinds of contacts are made with teachers or other school personnel. Also to what degree does the school-based health center become involved in supporting a healthy school environment?

Dental Health Challenges

Seven participants in The Robert Wood Johnson Foundation Caring for Kids initiative are developing dental programs within a school-based health center. This discussion summary re-caps their project plans and summarizes their perspectives on operational issues as well as data gathering and program evaluation.

Project Plans

St. John Community Investment Corp (Detroit, MI). Nancy Degroote, Corporate Director. St. John Community Investment Corporation operates 11 school-based health centers in the Detroit, Michigan area. They also operate several other free health centers for adults. The Caring for Kids project is their first foray into providing dental health services through the schools. The project looks to provide dental services to 4 of the school-based health centers through a mobile dental unit. The dentists will spend one week at a time at each of the 4 SBHC.

Methodist Health Care Ministries of South Texas, Inc. (San Antonio, TX). Joe Babb, Director, Clinical Services. The program will pilot a model for implementing a comprehensive school-based dental program in underserved communities. The model will include prevention, treatment and education components. The prevention component includes sealants, individualized fluoride treatments, mouth guard fabrication for sports, oral hygiene instruction, nutrition, tobacco use and early intervention. The treatment component includes essential services such as emergency, diagnostic, preventive and restorative care. A referral mechanism will be established for children requiring specialty care. Education will be provided to all elementary school students through integration with the regular curriculum and working with teachers, parents and oral health professionals. The program will be implemented in two school districts. It will be a collaborative effort of the Methodist Healthcare Ministries, the University of Texas Health Science Center at San Antonio the Texas Department of Health, community dental clinics, as well as the teachers, parents and administration of the respective schools.

Children’s Hospital of New Jersey (Newark, NJ). Rose Smith, Director of Community Clinical Services Through this project, Childrens Hospital of New Jersey will hire two outreach workers to assist children and parents to overcome multiple barriers to care. The outreach workers will work to achieve the following goals: 1) educate children and their families about the importance of dental health, 2) assist children in overcoming transportation and other systemic barriers to care, and 3) develop a tracking and monitoring system that can be replicated by similar programs. The project will develop a tracking system based on Clinical Fusion, a clinic management software program designed specifically for school based clinics.

Samuel U. Rodgers Community Health Center, Inc. (Kansas City, MO). Pat Mason-Dozier, Dental Director. The Samuel U. Rogers Community Health Center is establishing a comprehensive dental program within the McCoy Elementary School health center . Samuel Rodgers Health Center manages 5 school-based health centers and serves approximately 5,200. A dentist, dental hygienist, and dental aide as well as dental, dental hygiene and medical students will provide the new dental services. The dental team will provide exams, primary dental care, dental cleanings, and dental sealants. The project will serve school students in the first year, add their siblings and other family members in the second year, and extend care to residents of the immediate neighborhood in the third.

Health Establishments at Local Schools (HEALS), Inc. (Huntsville, AL). Tracey Wright, Administrative Director. HEALS’ dental clinic currently offers comprehensive dental care to Lincoln Elementary School students through volunteer dentists, dental hygienists and office staff. HEALS’ Bright Smiles Program will expand the current dental health program by hiring a full time dentist, hygienist, and dental assistant to the HEALS’ Cassidy Memorial Clinic. The addition of salaried staff will augment the volunteers and increase the number of patients seen at the HEALS dental clinic, and increase the opportunity to provide services to needy students in schools without a HEALS clinic. Having a staff dentist at the site will also allow HEALS to develop a clinical preceptorship with the University of Alabama School of Dentistry, and to work with National Service Corps SEARCH Dental Students.

New York Presbyterian/Columbia University (New York, NY) . Stephen Marshall, Assistant Dean, Patient Care. This project is a joint effort of the New York Presbyterian Hospital’s Ambulatory Care Network’s (NYPH/ACNC) sponsored by the Community Health and Education Program (CHEP) and the Columbia University School of Dental and Oral Surgery’s Community DentCare Network Program. The project will develop a comprehensive school-based dental program at the Family Academy, a New York City public school located in the Harlem community of northern Manhattan. This program will include establishing a two-chair dental suite within the Family Academy School-Based health center that will be staffed by dentists and dental hygienists. The business plan for the Family Academy comprehensive dental program projects a sustainable, self-supporting effort following the initial three years of operations

Operational Issues

Dennis Mitchell, facilitator: Let’s take a minute to identify each site’s major concern in implementing their dental program. Just say a little about the single most important concern you have. We’ll see if we can group the questions and then go back and identify some solutions or things that can be done.

  • St. Johns (Detroit) – How do we integrate children’s dental issues into the everyday thinking of medical staff? The St. John’s program is a mobile unit that provides dental services to many schools in the state. How can we get the medical staff at all the sites to incorporate dental into their daily thought process rather than just prepping for the day the dental van is coming.
  • Methodist Ministries (San Antonio): How do we overcome the complacency and/or disinterest of parents and the community as to the importance of dental health?
  • Children’s Hospital of New Jersey (Newark) – New Jersey’s program does not have a problem with integration of services, but they do not provide restorative dental care on site. They have to refer the patients to managed care providers and there are a lot of access issues, such as transportation and appointment shortages as well as missed appointments by patients. How do we secure access to restorative services for our patients? How do we engage the parents in this process? How do we enlist more providers?
  • Samuel Rodgers (Kansas City, MO): We have a similar problem to Methodist Ministries. How do we help parents share the responsibility of caring for their children? Our health center feels that parents look to it as taking over the responsibility for the care of their child. We want to help parents see themselves as partners in taking care of their children.
  • HEALS (Huntsville, AL): If we find a dentist and secure the parents’ help, how do we overcome transportation barriers? While HEALS has a very integrated system, we work with three school-based health centers and we have difficulty transporting the children from schools that don’t have dental services to those that do. We’re also having trouble hiring a full-time dentist at the salary we can offer.
  • Columbia U (NYC): Our challenge is: how do we integrate dental services with other health center services, such as nutrition, tobacco use, and injury prevention initiatives? We want to integrate dental services with the other physical services that are provided by the school-based health centers.
  • Montefiore (NYC): Space – how do we pay for renovation? Montefiore is working with the school site to construct the space for the dental clinic. Coordinating school board policies, personnel needs, and the construction process will be a challenge.

Seven Major Challenges for Dental Programs Within School-Based Health Centers

  • How to integrate children’s dental issues into the everyday thinking of medical staff?
  • How to overcome the complacency and/or disinterest of parents and community in the importance of dental health?
  • If program does not provide restorative services on site, how to secure access to those services? How parents engaged in this process?
  • How to help parents share in the responsibility of caring for their children?
  • How to integrate dental services with other health center services, ie. nutrition, tobacco use, injury prevention initiatives?
  • How to recruit and configure provider staff in rural areas?
  • Space – how to pay for renovation?

Strategies suggested

Issue 1. Integrate children’s dental issues into everyday thinking of medical staff.

The dental staff believe that all services are equally important, but medical think that dental is secondary. Dental should be seen as part of primary care. We in dental care know how important clinical integration is but our non-dental colleagues may not. We have to get over the idea that medical starts with the tonsils and goes down and dental starts with the mouth and stops at the tonsils.

Participants recommended the following:

  • Use a common consent form for dental, medical and mental health services. This will emphasize the range of care provided by the health center.
  • Introduce availability of dental services through classroom education
  • Schedule regular staff meetings that include all service components of the health center
  • Organize cross education of the medical and dental staffs
  • Integrate all clinical services within the patient chart

Issue 2. Overcome the complacency and/or disinterest of parents and community in the importance of dental health.

Methodist Ministries is seriously concerned that the community does not understand the value of the health care program in the school in general and dental care in particular. Their enrollment rate is only 20% of the student body. Methodist Ministries will be working to increase community understanding and parent support so that student enrollment reaches 40 or 50% in the current year.

Strategies suggested:

  • Schedule an open house and organize tours of the facilities to educate the community about what takes place at the site and how it can be an advantage to have their child enrolled.
  • Offer something specifically for parents. When approaching parents, you have to go with the positives. May need to educate the community about the importance of dental care if it’s not been a priority for older adults.
  • Make sure the information you provide to parents can be read and understood, with language and literacy level taken into account.

Issue 3. Secure access to services and engage parents in the process,

The New Jersey site provides preventive dental services on-site to all the enrolled students. The problem is that they do not provide restorative services on site and refer students to their managed care dentist for services. The issues they are trying to resolve center around long waits for appointments, no shows and the number of providers that will do the work. They have a system of sending follow up letters and reminders, but find that many parents do not follow up with the restorative work. Many of the recommendations to Issue 2 apply here.

Strategies suggested:

  • Target the community-based organizations, churches, police department and other groups to bring together for education and buy-in.
  • Open house
  • Offer something for the parents
  • Focus on assets of the community

Issue 4. Overcome or resolve policy barriers to sustainable dental practice and help parents share in the responsibility of caring for their children.

A lively discussion concerning the requirement at Samuel Rodgers that parents must be present for the dental professionals to provide restorative services to their children raised a number of issues. There have been cases in Missouri where dentists have been sued successfully because they provided services to minors without parental permission or parents being on site. Thus, the dental practice faces difficulties that are in part a function of organizational policy and in part a function of interpretation of court decisions and potential liability

Strategies suggested:

  • Work with colleagues at the organizational level to effect policy change that would allow practitioners to provide restorative care as long as signed parental consents are on file. It was suggested that the program also change its consent form so that when parents consent to preventive care they also consent to restorative care.
  • Consider a legislative strategy that would provide some protection for providers who care for children whose parents are unwilling to authorize needed restorative care.

Issue 5. Find a dentist and overcome transportation barriers,

HEALS has not been able to find a staff dentist due to the salary they have to offer ($35,000) for a three-day a week position.

Strategies suggested:

  • Craft full-time position even though need is only for 3 days. A National Health Service Corps position needs to be at least 32 hours a week.
  • Recruit SEARCH students. (SEARCH is an Alabama program that pays student stipends to dental and dental hygiene students to work in non-profit agencies serving underserved populations. If, upon graduation, these students choose to practice in an underserved location, the students may be eligible for a loan forgiveness program.)
  • Check into reciprocity laws in Alabama that allow dentists to get licenses more quickly if they work in underserved areas
  • Hire more than one dentist. HEALS may be able to contract with 3 dentists, each working one day a week.

Issue 6. Integrate dental services with other health center services, i.e. nutrition, tobacco use, injury prevention initiatives.

Columbia has created a pilot program that works with the local dental society to get volunteers for the school-based health centers. They have had about 5 percent of the local dental society volunteer and they are using these dentists to supplement and compliment the existing staff. Columbia is looking for ways to integrate its dental services with the other school-based health center programs such as nutrition and optometry.

Strategies suggested:

  • Use dental program to help track and monitor other medical issues
  • Conduct multi-disciplinary training
  • Organize cross-discipline meetings senior team meetings
  • Participate in provider meetings
  • Management of chronic disease with a dental perspective

Issue 7: Identify funding to pay for renovation and construction of facilities.

Montefiore is renovating space for its dental program. They are looking for ways to obtain capital funding for construction. They are also interested in ways of coordinating all facets of construction, while not having control over the process. The process involves school administrators, boards of education and construction entities. All participants agreed that if they can get the facilities built and enroll the kids, they can usually generate the revenues to keep them afloat.

Strategies suggested:

  • Ask the Center staff to look into RWJF acting as a liaison with other funders to obtain construction funding.
  • Work on policies to expand availability of federal dollars for non-FQHC institutions to provide health services to low-income communities.
  • Encourage foundations to consider supporting capital projects in addition to program grants.

Concluding Suggestions:

Workshop participants agreed that there were actions to be taken that would facilitate grantees continuing to exchange ideas and solve problems. These included having the National Program Office collect and share documents among the sites. As a first project, Annette Ferebee will collect and disseminate consent forms. The NPO was also asked to establish a listserv as well as post relevant documents and a literature review on the Center web site. There was also interest in sharing of quarterly reports – a suggestion that will be explored further by the NPO. Finally, workshop members suggested that the flip chart sheets be brought to the next annual meeting to see how well the suggestions worked!

Evaluation Issues

While the list of potential evaluation questions was a lengthy one, a smaller number were identified as worthy of exploration, with the recommendation that sites select two or three to focus on.

  • Demographics:  Who do we serve?
  • Access to care:  Have you ever seen a dentist?

      This question prompted a discussion about who you should ask:

      Do parents answer this question on behalf of their children? If so, it will be harder to get the information. Does a 6-year old? Is the response reliable? What about a 15-year-old?

      Where would you ask this question about dental history? On the consent form? At the first visit? Do you ask twice – both parent and kid?

      Subset access questions might include: Who is your dentist? When did you last see the dentist? The group agreed that posing questions to parents must be done carefully if the goal is to treat the child.

    * Outcome-focused questions would include the following:

      What are we doing that improves access?

      What are we doing that improves understanding of the importance of dental care, especially the importance of sealants?

      What is the quality of the services we provide?

      Are we improving the oral health of a community?

      How are we different from other dental providers?

      How do we relate to other services – medical and mental health – in the

      school-based health center?

      Are school-based dental services cost-effective compared to other models?

      What is the impact of SBHC medical services on the dental practice? What is the impact of the dental program on the rest of the school-based health center?

      How effective are dental services in school-based health centers in terms of Healthy People 2010 goals?

Megan Charlop, facilitator: Here are some of the questions that we have thought about asking. Some of them are pretty basic; others are a little harder to put your arms around. For example, are parents the best source of information? What has been the experience. you go with the parents?

Rose Smith, Newark, NJ: Sometimes the parents think their children should have seen a dentist or should have insurance so, sometimes they tell you yes even though the children have never seen a dentist and don’t have insurance.

Charlop: Sounds like many of you are using a combination package — kids and parents both. What do you do when you get conflicting information? How do you handle that?

Helen White, HEALS: Look in the child’s mouth. Have restorations have been done? Sometimes looking in the mouth gives you the best information.

Linda Juszczak: Think about the question you are asking and step back. Think of the larger question and think of the data elements needed to answer that question. If the question is, “Are we doing anything to improve access?”, then one of your questions is, “has the kid ever seen a dentist before?”

Charlop: Do people agree that’s the fundamental question we’re asking? Is that the key question: What are we doing to increase access?

What else is there? What are we doing to increase awareness of the importance of dental care and routine care? Is that a question?

And what about this old question: whose responsibility is it anyway? Where’s the parents’ responsibility to make sure children get good dental care and where is the health systems responsibility is to make sure all kids get dental care?

Mitchell: In our state, children with Medicaid have seen dentists. But they have fillings and no sealants. It’s a frustrating situation.

Juszczak: That sounds like a second question. Are you improving ACCESS? And what is the QUALITY of the services that are being provided? As several of you spoke about the services that kids are getting in the community outside of your facilities, it sounds like some of that care is questionable. So somehow you want to capture that comparative information.

Two other questions not to forget: First, how are we different in providing those dental services then other places? What is it that is different about dental services in schools as opposed to dental services in a community health center or public health clinic or private office? And second, since all of you are part of comprehensive programs, how do you relate to the other health care services provided at the school-based health centers?

Mitchell: We can’t serve students or collect data without parent signatures on a consent form. And we try to ask parents a few key questions on that form. When you are a comprehensive program, what is realistic to ask on the consent form? What are the questions that are most important to dental health? How do you that list down to no more than three for the consent form? You can involve children in every question but not the parents.

Charlop: When you do comprehensive permission slip for services, do you do another one for preventive and another restorative services or do you just have one consent?

Mitchell: It depends on the school partners. We do both.

Charlop: When you use the one consent form, do you go back to the parents to update them – even when you don’t need an additional consent?

Mitchell: In every case. In middle schools we use notices in backpacks; in elementary schools, we mail information home. And we follow up with phone messages.

Timing is also important in our work. The best time to get consents is at the beginning of school year. We send consents home with the school orientation package. Going back later can be difficult and unproductive. So we try to get everything in the initial orientation package.

Unknown: What kinds of questions can we ask to look at outcomes?

Charlop: So, is the question — are we improving oral health? Are we improving quality of dental care compared to some other dental service?

Steven Marshall, Columbia U, NYC: I think we should stay away from quality issues. First of all, I don’t think you can really measure it and second, if you say you provide higher quality care than community providers, then that is inflammatory.

Charlop: But you need to ask some quality questions even if you don’t do it comparatively, correct?

Marshall: We do our own quality assurance things so that we can start to say we provide higher quality care than is customarily available to these kids.

Charlop: In addition to the access question of “Have you seen a dentist?” Do you ask why or why not? Do you ask if the family has dental insurance? Have you asked and then decided that it’s not a good idea?

Mitchell: We talked it through and decided that if our purpose is to treat the child, then we have to be careful about not scaring off the parents. Asking these questions may be a dangerous path if the goal is to treat the child. Our situation is particularly affected by the fact we have a large number of undocumented families.

Unknown: I think access is easier to measure. If you line up 100 children before a dentist with a flashlight, you can measure access regardless of other concerns. If that child has decay, it is an access problem. We can measure the state of those mouths.

Pat Mason-Dozier, Samuel Rogers Health Center, Kansas City: Is it meaningful to measure access and not the reason why? If we are going to change the system and change access, don’t we need to know why you haven’t seen the dentist? Is it because you can’t get an appointment? Is it because you can ‘t get transportation, or don’t have insurance?

Marshall: I think that is a good question. This is a service grant and a service program

Charlop: Do I hear some of you saving that ultimately we are here about the service not evaluation and we can’t risk service to pursue an evaluation goal.

Mason-Dozier: If we’re going to use these evaluation studies down the road to change policy, then is it meaningful or helpful to just say we have an access problem but not know why?

Lear: It seems to me that if you want to influence the field you’ve got to ask some of the questions Pat is asking. Does everyone have to do it? I don’t think so. What I’m hoping is that we’re going to see interesting, but not necessarily the same, insights from all the projects.

Mitchell: Our projects are at different places. New York wants to look at risk assessment. We want to see why some kids are free of caries and they live in the same environment as kids with major dental problems. We want to see what makes them different. That’s a different place from the straight-forward access questions we asked when we were starting out but it took us seven years to get there.

Conference Participants

DENTAL HEALTH GRANTEES

Children’s Hospital of New Jersey

Rose Smith, MS, RNC
Director, Community Clinical Services
Children’s Hospital of New Jersey
201 Lyons Avenue, L-G
Newark, NJ 07112
Phone: 973-926-4805
Fax: 973-926-6186
rosmith@sbhcs.com

Isaac McGregor, Jr.
Caring for Kids – Outreach Worker
Children’s Hospital of New Jersey
201 Lyons Avenue, L-G
Newark, NJ 07112
Phone: 973-705-3880
Fax: 973-926-4510
HEALS, Incorporated

Priscilla Condon, CRNP, MSN
Clinical Director
HEALS, Incorporated
1216 Meridian Street
Huntsville, AL 35801
Phone: 256-428-7275
Fax: 256-428-7274

Tracey Wright
Administrative Director
HEALS, Incorporated
1216 Meridian Street
Huntsville, AL 35801
Phone: 256-428-7275
Fax: 256-428-7274
twright@hsv.k12.al.us

Methodist Health Care Ministries

Joe Babb
Project Director
Methodist Health Care Ministries
4507 Medical Drive
San Antonio, TX 78229
Phone: 210-692-0564
Fax: 210-614-7563
jbabb@mhm.org

Sherry Jenkins
Dental Hygienist
Methodist Care Ministries
306 South Cunningham
Marion, TX 78124
Phone: 830-914-2803, ext. 111
Fax: 830-914-2803
sjenkins@the-i-net

Montefiore Medical Center

Victor Badner, DMD, MPH
GPR and DPH Director
Montefiore Medical Center
106 West Garden Road
Larchmont, NY 10538
Phone: 718-918-3418
Fax: 718-824-4547
VBadner@Montefiore.org

Megan Charlop
Operations Manager
Montefiore Medical Center
3544 Jerome Avenue
Bronx, NY 10467
Phone: 718-920-6020
Fax: 718-515-7741
Mcharlop@Montefiore.org

New York Presbyterian Hospital

Stephen Marshall, DDS, MPH
Associate Dean, Extramural Programs
New York Presbyterian Hospital
630 West 168th Street
P&S Box 20
New York, NY 10032
Phone: 212-305-0764
Fax: 212-305-6032
sm15@columbia.edu

Lorraine Tiezzi, MS
Director, Community Health &
Education Program
Columbia University School of Public Health
60 Haven Avenue, #B-3
New York, NY 10032
Phone: 212-304-5240
LT3@columbia.edu

Samuel U. Rodgers
Community Health Center

Pat Mason-Dozier, DDS
Dental Director
Samuel U. Rodgers
Community Health Center
825 Euclid
Kansas City, MO 64124
Phone: 816-889-4738
Fax: 816-474-6475
cmason-dozier@samuel-rodgers.org

Teresa Mills
Director of Development
Assistant Project Director
Samuel U. Rodgers
Community Health Center
825 Euclid
Kansas City, MO 64124
Phone: 816-889-4621
Fax: 816-474-6475
tmills@samuel-rodgers.org

St. John Community Investment Corporation

Nancy Degroote
Corporate Director
St. John Community Investment Corporation
22101 Moross Road, #365
Detroit, MI 48236
Phone: 313-343-7734
Fax: 313-343-7801
nancy.degroote@stjohn.org

Marcy Borofsky, DDS
St. John Community Investment Corporation
25882 Orchard Lake Road, #105
Farmington Hills, MI 48336
Phone: 248-442-6600
Fax: 248-442-7099
Mobdent1@aol.com

Margo Woll, DDS
Dental Director
St. John Community Investment Corporation
25882 Orchard Lake Road, #105
Farmington Hills, MI 48336
Phone: 248-442-6600
Fax: 248-442-7099
myw18@aol.com

The Robert Wood Johnson Foundation
Judy Stavisky, MEd, MPH
Senior Program Officer
The Robert Wood Johnson Foundation
Route One and College Road East
P.O. Box 2316
Princeton, NJ 08543-2316
Phone: 609-951-5755
Fax: 609-627-6406
Jstavisky@rwjf.org

Liisa Rand
Financial Analyst
The Robert Wood Johnson Foundation
Route One and College Road East
P.O. Box 2316
Princeton, NJ 08543-2316
Phone: 609-243-5246
Fax: 609-627-5416
LRAND@rwjf.org

Guests
Bruce P. Guernsey, MSW
Director, Adolescent and School Health
Colorado Dept. of Public Health & Environment
4300 Cherry Creek Drive South
FCHSD-AH-A4
Denver, CO 80246
Phone: 303-692-2377
Fax: 303-782-5576
Bruce.Guernsey@state.co.us

Linda Juszczak DNSc, MPH, CPNP
Director of Education and Training
Institute of School-Based at
Montefiore Medical Center
Albert Einstein College of
Medicine and
Director, Center for Evaluation and Quality
National Assembly on
School-Based Health Care
3544 Jerome Avenue
Bronx, New York 10467
Phone: 718-920-6063
Fax: 718-515-7741
ljuszczak@montefiore.org

Patsy Trujillo Knauer
NM State Representative
New Mexico Legislature
Box 15532
Santa Fe, NM 87506
Phone: 955-1812
Fax: 505-955-1811
Sfcp@cybermesa.com

Dennis A. Mitchell, DDS, MPH
Director, Central Harlem DentCare Program
Director, Research and Community Dentistry
Harlem Hospital Center
Columbia University
School of Dental & Oral Surgery
630 West 168th Street, P&S 3-454F
New York, NY 10032
Phone: 212-304-7171
Fax: 212-305-6032
dml48@columbia.edu

John Schlitt, MSW
Executive Director
National Assembly on
School-Based Health Care
666 11th Street, NW, Suite 735
Washington, DC 20001
Phone: 202-638-5872
Fax: 202-638-5879
jschlitt@nasbhc.org

Regina (Jean) Villa, RN, MPA
President
Regina Villa Associates, Inc.
59 Temple Place, Suite 407
Boston, MA 02111
Phone: 617-357-5772
Fax: 617-357-8361
Ang2002612@aol.com

MENTAL HEALTH GRANTEES

Buncombe County Health Department

Nelle Gregory, RN, MPH
School Health Supervisor
Buncombe County Health Department
35 Woodfin Street
Asheville, NC 28801
Phone: 828-250-5056
Fax: 828-255-5319
gregorn@co.buncombe.nc.us

Ellen Riegg, RN
Asheville Middle School
Student Health Center Site Manager
197 South French Broad Avenue
Asheville, NC 28801
Phone: 828 255-5435
Fax: 828 255-5440 fax
riegge@co.buncombe.nc.us

Children’s Aid Society

Scott Bloom, CSW
Director of Mental Health
School-Based Clinics
Children’s Aid Society
4600 Broadway
NYC, NY 10040
Phone: 212-569-2859
Fax: 212-544-7561
ScottB@childrensaidsociety.org

Beverly Colon, PA
Director of Health Services
Children’s Aid Society
150 East 45th Street
New York, NY 10017
Phone: 212-949-4958
Fax: 212-986-9635
BeverlyC@Childrensaidsociety.org

Kelly Kirby, CSW
Senior Social Worker
Children’s Aid Society
4600 Broadway
New York, NY 10040
Phone: 212-569-2859
Fax: 212-544-7561

Children’s Hospital of Los Angeles

TuLynn Smylie, JD
Director, School-Based Health Program
Children’s Hospital Los Angeles
5000 Sunset Blvd, 4th Floor, MS 2
P.O. Box 54700
Los Angeles, CA 90027
Phone: 323-669-5987
Fax: 323-913-3614
tsmylie@chla.usc.edu

Julie McAvoy, MPH
Associate Director
School-Based Health Program
Children’s Hospital Los Angeles
5000 Sunset Blvd, 4th Floor, MS 2
P.O. Box 54700
Los Angeles, CA 90027
Phone: 323-669-2450, ext. 5023
Fax: 323-913-3614
jmcavoy@chla.usc.edu

Kerri Pickering-Fowler, PsyD
Coordinator LAHS Mental Health Services
Division of Adolescent Medicine
Children’s Hospital Los Angeles
P.O. Box 54700, MS#2
Los Angeles, CA 90054-0700
Phone: 323-936-1046
Fax: 323-913-3614
kpickering@chla.usc.edu

Dorchester County Health Department

Kathleen Wise, LCSW-C
Program Administrator
Dorchester County Health Department
403 Race Street
Cambridge, MD 21613
Phone: 410-901-2388
Fax: 410-901-2385
hfd@fastol.com

Mona Carey, LCSW-C
Dorchester County Health Department
403 Race Street
Cambridge, MD 21613
Phone: 410-228-0973
mlwc@fastol.com

Long Island Jewish Medical Center

Martha Arden, MD
Project Director
Division of Adolescent Medicine
Schneider-Children’s Hospital
410 Lakeville Road, Suite 108
New Hyde Park, NY 11040
Phone: 516-465-3270
Fax: 516-465-5299
marthaarden@juno.com

Marco Martorano, ACSW
Social Work Supervisor, Clinical
Franklin K Lane High School Student Health
999 Jamaica Avenue
Brooklyn, NY 11208
Phone: 718-235-1087
Fax: 718-235-1291
Lynn Community Health, Inc.

Lili Silva, MMHS
SBHC Administrative Director
Lynn Community Health Center
269 Union Street
Lynn, MA 01901
Phone: 781-596-2502 ext. 705
Fax: 781-596-3966
lsilva@lchcnet.org

Kristen Donovan, MSN, RNCS
Clinician
Lynn Community Health Center
269 Union Street
Lynn, MA 01901
Attention: Behavioral Health Department
Phone: 781-581-3900
Fax: 781-598-8137
kdonovan@lchcnet.org

Seattle King County
Department of Public Health

Linda St. Clair
Manager, Youth Health Services
Seattle King County Dept. of Public Health
999 3rd Avenue, Suite 1200
Seattle, WA 98104
Phone: 206-205-0600
Fax: 206-205-5670
Linda.st.clair@metrokc.gov

TJ Cosgrove
Project Coordinator
Seattle King County Dept. of Public Health
999 3rd Avenue, Suite 1200
Seattle, WA 98104
Phone: 206-296-4987
Fax: 206-205-5670
TJ.cosgrove@metrokc.gov

University of New Mexico

Martin J. Kileen, MD, MPH
Assistant Professor in Pediatrics
CDC assignee
University of New Mexico, Dept. of Pediatrics
Center for Health Promotion
and Disease Prevention
Surge Building Room 251
2701 Frontier Street NE
Albuquerque, NM 87131
Phone: (505) 272-4462
Fax: (505) 272-4857
kileen@salud.unm.edu

Steven Adelsheim, MD
Associate Professor of Psychiatry, Pediatrics, Family and Community Medicine
NM DOH, Office of School Health
625 Silver SW Suite 201
Albuquerque, NM 87102
Phone: 505-841-5879
Fax: 505-841-5885
stevea@doh.state.nm.us

Nissa Patterson, MPH
Health Education Manager
ACL Teen Centers
UNM Center for Health Promotion and
Disease Prevention, 251 Surge Building
2701 Frontier Drive
Albuquerque, NM 87131
PHONE: 505- 272-4462
FAX: 505-272-4857
NPatterson@salud.unm.edu

Emily Spade, PsyD
Clinical Psychologist
UNM Center for Health Promotion and Disease Prevention, ACL Teen Centers
2701 Frontier Drive, Surge 251
Albuquerque, NM 87131
Phone: 505-272-4462
Fax: 505-272-4857
espade@salud.unm.edu

The Center for Health and Health Care in Schools

Julia Graham Lear, PhD
Director, CHHCS
jgl@gwu.edu

Annette Ferebee, MPH
Deputy Director, CHHCS
ajf@gwu.edu

Nancy Eichner, MUP
Senior Program Manager, CHHCS
Neichner@gwu.edu

Theresa Chapman
Executive Coordinator, CHHCS
chapman@gwu.edu