New York State Department of Health – School Health Program
School-Based Health Centers Mental Health Work Group Final Report
Background: Work Group and Consultant Collaboration on Mental Health
Through collaboration between the NYS Department of Health School Health Program and mental health consultant Rose Starr, DSW,* a work group of School-Based Health Center (SBHC) providers and State Education, Mental Health and Health officials was established to design the next generation of guidelines on the incorporation of mental health services and programs into SBHC practice. Funded by the Robert Wood Johnson Foundation, this effort involved the identification of key issues and areas for improvement as well as the participation of relevant stakeholders and mental health consultants in the design and recommendation process.
The project proposal by Dr. Starr outlined three areas for work group discussion and documentation: mental health program and service designs, staffing patterns and administration, and guidelines on record keeping and confidentiality. These provided the basis for small group deliberation on “Service Provision Models,” “Staffing and Administration” and “Guidelines for Practice (accountability, confidentiality, communication)” at the first work group meeting July 12, 2000, in Albany, NY.
Based on this meeting, the document entitled “Summary of Issues and Recommendations for Next Steps” (October 31, 2000) outlined the following issues and raised a series of questions for further work group discussion:
- Confidentiality in the context of SBHC relationships: clients, school and community
- “Parsing” confidentiality
- Records, forms and procedures for communication and collaboration
- Effective use of SBHCs for student well-being: the prevention-treatment continuum of service and related finance issues
- Consensus on SBHC direction, integration and evaluation
- Background and context of the discussion: balancing mission and maintenance
- Goals, roles, models and funding
* Project Director, Rose Starr, is Director of Policy and Research, School Mental Health Alliance, North Shore – LIJ Health System, and Associate Professor, Hunter College School of Social Work. She has developed school-based mental health training programs with the NYS Department of Health and Office of Mental Health and is a research consultant to OMH and the State Education Department on the School Support Project.
This document also provided the starting point for experienced mental health and SBHC practitioner consultants to offer their expertise to the project on questions of SBHC mental health services design and delivery.
Participating as consultants were Rona Novick, PhD., Director of Clinical Programs and Services for the School Mental Health Alliance, North Shore-LIJ Health System; Mary Courtney, PhD., Director of School Mental Health, New York University Child Study Center; Ellen Landau, CSW, family therapist and Director of the Family Center, School Mental Health Alliance NS-LIJ Health System. Linda Juszczak, P.N.P., Adolescent Medicine, NS-LIJ Health System, a nationally-recognized SBHC leader and former director of two North Shore University Hospital SBHCs, brought both theoretical and practical knowledge of the realities and trends in SBHC medical and mental health practice locally and nationwide.
Representing psychology, nursing and social work as well as psychodynamic and behavioral perspectives, the consultants brought in-depth experience in child, adolescent and family treatment and outpatient, crisis, inpatient, school-based and community programming. Specializations include ADHD, anxiety disorders, behavior/conduct disorders, anti-bullying/violence prevention programs, chronic disease and multiple-family therapy.
Consultants’ Focus: How to Think About SBHC Mental Health Services and Service Delivery
After reviewing current literature and documents on SBHCs and mental health as well as the project’s objectives and time frame, the consultants met as a group seven times from December 12, 2000 through February 26, 2001.
They defined as their contribution to the March 12, 2001, final Albany work group meeting a framework and related written materials that included core mental health activities, minimum requirements for mental health practice, a philosophical foundation, and practice recommendations:
- Core SBHC Mental Health Activities (see Appendix A.):
- Locating students who could benefit from intervention (aka “early identification”).
- Assessment and evaluation, including SBHC intake and mental health diagnostic evaluation, as needed.
- Individual, group and family counseling/treatment.
- Service coordination, including referral and follow-up.
- Prevention/early intervention.The consultants agreed that these activities form the primary areas of responsibility for the mental health worker in collaboration with other members of the SBHC team, school and community personnel. As keystone functions for mental health practice, it was presumed that perspectives and agreements on their scope and shape would frame further discussion and decisions about staffing, administration, training, and practice procedures.Utilizing as a model the Making the Grade Continuous Quality Improvement Tool for SBHCs (draft 10/30/00), the consultants highlighted the following dimensions of core activities:
- Definition and standards of practice – what the core activity encompasses and, all things being equal, how the mental health community would define best practices.
- Resources, including:
- prerequisite conditions – what needs to be in place in the SBHC or school as foundation requirements, and
- strategies and tools – available, effective approaches, methods and materials to help perform the activity effectively and efficiently.
- Target populations by condition, age, etc. – priority individuals or groups in the SBHC or school to whom specific activities should be directed.
- Level of effort – the approximate amount of time per week that the mental health practitioner, offering a well-rounded mental health program, should spend on each core activity.The consultants are grateful to Mark Weist, PhD., Director of the Center for School Mental Health Assistance, for sharing the results of the July 2000 Critical Issues Planning Session, “Addressing Mental Health Issues within School-Based Health Centers,” which served as a comprehensive overview and reality check for this work.In addition to recommendations on core activities, the consultants highlighted a set of foundation requirements for SBHC mental health service provision, the presence of which are considered essential for adequate, let alone effective, mental health operations: These “fundamentals” underpin and support those identified as necessary for the core mental health activities, and include:
- Minimum Requirements for SBHC Mental Health Service Provision
- Confidential space for SBHC team meetings, client interviews, group sessions, and staff consultations. This includes locked file cabinets for case records.
- Adequate time for team meetings and case conferencing upon initial client assessment, mental health diagnostic evaluation, and, as needed, for follow-up and periodic review and consultation.
- Standards on charting and chart review.
- Identification of diagnostic categories based on DSM-4 criteria.
- Consent for treatment from appropriate family member or, if age 18, the student/client.
- Policies on confidentiality of records and related procedures for sharing information with family members, school authorities and staff, and outside agencies, including SBHC sponsors.
- Collaborative relationships with and appropriate access to key school leaders and staff.
- Appropriate access to mental health-related coordinating or decisionmaking bodies.
- Systematic review and evaluation of programs, practices and procedures.Philosophical and Conceptual FoundationThe consensus that evolved among the consultants on the following concepts and beliefs provided the context for the particular shape and direction of their recommendations on core activities:
- Mental health activities are not the sole concern of the SBHC mental health practitioner. For reasons of both efficiency and effectiveness, mental health and health “silos” should be eliminated in SBHC practice (if it exists) in favor of inter-disciplinary teamwork and triage of often inter-related health and mental health concerns.
- High student need and limited SBHC mental health staffing require that the mental health practitioner leverage her/his skills and reach by recruiting, training and utilizing additional professionals from the SBHC, the school and the community to extend SBHC mental health programs.Utilization of volunteers (students, family and community members) may be helpful in the development of prevention programs, such as mentoring, community education, access to resources, assistance with transitions, and anti-violence initiatives. Involvement of volunteers is a long-term investment that can release SBHC professionals to address specific clinical, supervisory and programmatic needs.
- To reduce the inevitable overload associated with high need and limited clinical resources, it is essential that the mental health practitioner distinguish between the majority of enrolled students’ social and emotional problems and the minority with diagnosable mental illness.The former or broad base of need can be addressed through universal, supportive, educational, and group interventions provided by a range of personnel. The latter, narrower type of need requires expert mental health assistance from the SBHC or other properly trained mental health providers in the school or community.The necessity is not only for resource-finding and utilization on behalf of individual students/clients but resource development and creation to address gaps in existing programs and services that affect student health and well-being.
With these distinctions as a frame for service, the mental health practitioner can provide time-limited treatment services for those with particular types of mental health problems. To be both effective and responsible, such a short-term model of service must be wedded to a required, periodic re-assessment process by the SBHC team responsible for determining ongoing needs, resources and recommended treatment plans.
- The priority issues or target problems and populations for mental health practitioner attention should be periodically reassessed by the SBHC team, with school and community input. To do otherwise is to risk lack of congruence between perceived serious needs and optimal application of SBHC resources.Similarly, to assure the most appropriate use of SBHC mental health practitioner time and expertise, it is important to understand and balance diverse definitions of need by multiple SBHC stakeholders. For example, school leaders’ primary interest in SBHC staff as providers of crisis intervention on a range of behavior and safety problems may be appropriate to establish credibility in the early phases of service development or in true emergency situations, but not as an ongoing SBHC mental health function.
- Given the size of schools in which SBHCs are located as well as their changing needs and conditions, yearly reaffirmation or renegotiation of services and priorities is recommended. Similarly, yearly communication to school staff, students and families is necessary to increase the likelihood of support and appropriate utilization.
- A host of tensions and conflicts are built into the structure and function of SBHCs. They should be recognized, articulated, and addressed to the extent possible, recognizing that their total elimination is unlikely. Two that bear on the relationship of the SBHC to its host school are as follows:
- School leadership matters. The status and function of an SBHC and its level of acceptance by and integration into the school community is contingent upon the support and leadership of school (and district) leadership personnel. SBHCs are vulnerable to and constrained by changing leadership and related changing concerns and priorities.
- Collaboration and advocacy. The exhortation to SBHCs to collaborate with their host schools on health and mental health concerns should be understood within the context of their related but different missions. The best interests of a child as SBHC client may conflict with a school’s perceptions of its interests or that of the broader school community. Tensions inevitably surface between SBHCs as child health and mental health advocates and schools as educational institutions functioning “in loco parentis” for all students.Strategies to keep these tensions in check and reduce their severity when they occur include the development of trusting staff relationships over time and a mutual focus on children’s learning and achievement. The former can lead to “agreement to disagree” rather than ruptured relationships and hostilities. A focus on academic performance can provide a common platform for diverse perspectives and skills.Recommendations
Taking Control: Suggested Mental Health Service Delivery Design
The core activities and minimum requirements outlined above exist within a fluid and ongoing service delivery process that is crucial to the sound and successful operation of an SBHC mental health component. The core activities and mental health service delivery system recommended by the consultants were endorsed and refined through discussion with the work group (see Appendices A and B) and incorporate the concepts and philosophy previously identified.
This conceptualization provides a tool to SBHCs and the mental health provider to organize and thus take control of the mental health service component. We believe that these mechanisms and strategies are responsive to the expressed needs and concerns of mental health providers in diverse areas of the State who have told us they are overwhelmed by the extent of need they address and the minimal community or school resource available or accessible to youth in trouble outside of the SBHC.
This kind of service delivery pattern can provide protection to mental health providers struggling to balance immediate clinical needs with pressures to do more – whether that be to reach out and collaborate, to engage in prevention programs, or to educate and evaluate.
In addition, application of this service delivery design can promote good practice as well as professional accountability: each modality and intervention is linked to and justified by timely and appropriate assessment or diagnostic evaluation.
Program and Management Structures
In our view, judicious use of the following program and management activities and structures embedded in the service delivery system can permit a well-rounded, feasible mental health operation:
A statement on the credentials of the mental health supervisor and related supervisory activities is offered to assist in on-going efforts to define this requirement. The statement (see attached), incorporating input from work group participants and mental health consultants, reflects concern for high quality and accountability as well as SBHC practice realities.
Finally, we offer the following Levels of Care Grid on the type of assessment and staffing most appropriate to diverse problems with different degrees of intensity (see Appendix E.). This tool, an adjunct to the service delivery flow chart, can help the SBHC sort out when and where interdisciplinary team or mental health provider involvement are recommended.
These perspectives and recommendations are offered in an effort to provide alternative ways of thinking about the role of the mental health professional and mental health services in the context of the SBHC mission and team. We trust that this work will pave the way for further discussion and elaboration of key issues, problems and potentials, so that:
- Multi-disciplinary teamwork and periodic case conferencing.
- Utilization of a Drop-In Center concept (Appendix C.) to watch and support students with particular mental health issues and characteristics.
- Collaborative and differential deployment of the mental health provider and SBHC medical staff.
- Approximate time ranges for the five core mental health activities and recommended administration, supervision and education (see Appendix D pie chart).
- Supervision and continuing education for the mental health professional in particular and SBHC mental health service providers in general.
- The SBHC mission and mental health expertise can continue to shape an effective and feasible SBHC mental health service system.
- The next generation of SBHC mental health service guidelines are informed by the continued collaboration of SBHC providers, mental health experts, and NYState Department of Health, Education and Mental Health officials.
- Mental health service system requirements can stimulate planful, interdisciplinary programs of continuing education and mutual support.