hot topic

Note to Agency partners: Why School-owned Student Support Staff are So Important

A major goal of school and community collaboration is to increase the resources available to meet the mission of schools....This positive intent is steadily being undermined as some policy makers have come to the mistaken view that community agency services can effectively meet the needs of schools in addressing barriers to learning and teaching. And, with budget tightening, school administrators and school boards are making the difficult decision about what to cut based on this erroneous conclusion. This set of circumstances has led to an increased trend toward reducing school owned student support staff and contracting with community agencies for specific services.
    Unfortunately, this short-sighted budget slashing strategy not only reduces the amount of student support needed by teachers and schools, it also counters school improvement efforts designed to reframe support programs, services, and infrastructure into a potent and invaluable system of learning supports that is fully integrated with the school's educational mission.
   By themselves, the type of clinical services community agencies can bring to schools are an insufficient strategy for dealing with the biggest problems confronting schools. Clinically oriented services are only one facet of any effort to develop a comprehensive system of learning supports. These are not criticisms of the services per se. It is simply the fact that such services do too little to address the range of factors that cause poor academic performance, dropouts, gang violence, teenage pregnancy, substance abuse, racial conflict, and so forth.
   The trend to contract for specific support services ignores the following crucial reasons school owned student support staff are so important:
        • Direct services for the discrete problems of a small
            number of students are only a small part of what a
            school and district need in terms of learning supports
           (including ways to address mental health and
           psychosocial concerns).
        • School-owned student support staff are meant to
            address the needs of all students and the school at
            large. To these ends, they pursue development of a
            full continuum of interventions and related
            infrastructure, using the sparse resources community
            agencies can offer to fill gaps in the continuum.
        • Without the full continuum of student/learning support
            interventions, school improvement efforts are unlikely
            to effectively counter behavior problems, close the
           achievement gap, reduce dropouts (students and
           teachers), and promote personal and social well being
           for the many.
    The need is for school-community collaborations that can evolve comprehensive, integrated approaches by complementing and enhancing what each sector does best. Such approaches do more than can be accomplished by a few contracted community services. They address a wide array of the most prevalent barriers to learning – the ones that parents and teachers know are the major factors interfering with the progress of the majority of students.
    By coordinating and integrating with each other and with community resources, school personnel can enhance the mental health of increasing numbers of students. The success of efforts to integrate school and community resources depends on a variety of factors -- a clear policy vision of why integrated efforts are important, leadership and a critical mass of committed colleagues, mechanisms and processes that can overcome challenges to collaboration, time to plan, support at each step of the way, appropriate accountability. It is not an easy process, but the rewards for all involved can be great. These can include greater intervention effectiveness and a strengthened sense of community. And, the success of such efforts should help schools see the integral part mental health programs can play in reducing barriers to learning, and this should contribute to greater support and acceptance of the programs."

A Few Other Resources Relevant to the Topic

>School-community alliances enhance mental health services
http://pdkintl.org/noindex/NASP-articles/57pdk_96_4.pdf
>Strategies to develop mental health models in schools https://ct.counseling.org/2018/03/five-strategies-develop-mental-health-models-schools/
>Time for Straight Talk about Mental Health Services and MH in Schools
https://smhp.psych.ucla.edu/pdfdocs/mhinschools.pdf
>Embedding Mental Health into a Learning Supports Component: An Essential Step for the Field to Take Now https://smhp.psych.ucla.edu/pdfdocs/embeddingmh.pdf

Then, we received this from a colleague:

The issue I have had with community agencies coming into the school to provide mental health services is they only want to work with Medi-cal eligible students so they can bill the State for their services. I feel this is discriminatory, and if the school has few or no other staff to provide these services, other students in need are left without. I feel that any agreement with community based organizations (CBOs) to provide mental health services should require that a percentage of students that they serve do not have to have Medi-cal eligibility.

Another concern is that some of these CBOs do not want to share the names or other information about the students they are seeing because of "confidentiality"...A pure model of confidentiality is not possible in schools, especially the school's Coordination of Services team who need to do resource mapping related to student needs to make sure that whatever opportunities, services and supports available at the school are not duplicated when the resources are so few. On the teams I have worked with, it has been important to have the names of all students "at risk" that are being served and by what program or service provider(s). This helps to make sure that as many students as possible are getting some services that hopefully will be of value to them.

We shared his concerns with a number of other colleagues working in schools, and here is a sample of what they shared back:

(1) As for confidentiality, the release to share information on a need to know basis may be included as part if the contract or interagency agreement signed by provider and district.
In California we have monies reimbursed by the state 'Local Education Agency and Mental Health Administration' funds, money paid by Student Services from McKinney Vento monies and perhaps other Grant's for instance tobacco prevention... These monies are used to contract with a range of providers some of which take the insurance or have sliding scale payments.
    Yes, our Community Support Services takes Medi-Cal and this is hard because this agency provides psychiatric services. However, our community Support Liasons are great in finding resources to connect families with. Families with insurance may also access service at the school site sometimes, particularly when parent time or ability to travel get in the way of student getting service. The scope of need is so broad and so intense that gaps do surface throughout the year and this is challenging.

(2) There really should be no issue with community agencies coming into the school to provide mental health services. It is a well needed service for those without the resources or means to receive mental health care. I understand the concern about only serving Medicaid eligible students but I would not go as far to say it is a discriminatory practice. Granted all public schools have few or many times no other staff to provide the services. I would say this point is very valid and should be a top priority for the department of education on a national level. When CBO's come into a school we have to remember they are just taking their practice and transplanting it within school walls. In essence they are bringing the service to the students and families to eliminate the barriers toward accessing the services. This can blur the lines of confidentiality but typically the individuals providing the mental health services are licensed or have a state code of ethics regarding what they can and can't divulge. With that said the leader of the learning organization should set up a meeting with the director of the CBO to understand and/or negotiate various points of the Memorandum of Agreement (MOA) allowing the services to occur in the building or district. In addition, the confidentiality piece should be discussed because there are certain parameters that can be shared at the building level with both the principal and the guidance counselor. I do understand the frustration that seems to be coming from the sender but there are remedies to some of the concerns.

(3) This is a long standing problem of equal access to school mental health services. The funding of mental health services through Medicaid is a vital component to access for many of our most vulnerable children, including those receiving special education and related services. Finding ways to serve children who are not eligible for Medicaid using our clinical partners is complicated and may require MOUs with agencies and charitable organizations to partner with the schools in finding the funding. I found that schools and the local county interagency councils were able to overcome some of the funding barriers through cooperative agreements and MOUs that enabled service delivery to non-Medicaid eligible children. But that model may work only where so many children in the school system are eligible it de facto makes all eligible. Regardless, the cost of services is always higher than the Medicaid reimbursement. I believe that Medicaid reimbursement for in-school services is about 60-70%. I would encourage systems to explore multiple funding resources.
    Second issue of sharing information and confidentiality. The best functional model for schools is using the skills of practitioners and sharing information with consent. I found that the most effective schools were including clinicians in the teams for children they were serving. Many were even using their community partners as "consultants" invited by school mental health persons. The misuse of Confidentiality can be a barrier to using services effectively. Clinicians and school staff should be respected for their skills in knowing what to share and how to not violate privacy rights. Agencies and schools should look at how confidentiality is respected but not blocking effectiveness.”

(4) There are two big issues raised. First, the issue of ‘only working with Medi-Cal eligible students’. In the State of California this has been a problem for a long time. Students and families who are receiving mental health services through Medi-Cal are provided complete care. Once they cross the line of being ineligible for Med-Cal, those services disappear. Those students and families must rely on insurance or pay out of pocket for services, usually neither option is viable.
     Community agencies many years ago could access funds for these students and families, but those have seemed to dried up. It is a problem that needs to be addressed. Currently, I’m aware of districts addressing this either by looking at those services that community agencies provide and redirecting their internal resources to those students and families that are not covered by Medi-Cal. I have known districts that looked at that as a cost savings and through redirected funding for some services. I do agree that when community-based agencies are invited on school sites, that part of a MOU, could negotiate that a percentage of non-Medi-Cal students and families that would be served. This would be part of the partnership between the school and the agency based on the simple fact that the school is providing clients for the agency that generates funding. The question would be what would be the appropriate percentage of students serviced, so the agency total funding is covered.
    The second issue is confidentiality. This is an issue that I have seen schools struggle with internally within their site and throughout their district. Once you add community agencies to this mix, it can get very complicated. When schools and districts move to a model of Coordinated Services, there needs to be an agreement about the sharing of information. With all the concerns about privacy and adding confidentiality to the mix, school are need to be very clear about how information is handled. There needs to be clear district policies in place that all party agree on. Those policies need to be reviewed by proper legal authority to be sure everything meets the current laws. When it comes to community agencies working in the schools, they need to also agree to operate within these policies. It is important to remember that agencies are invited to work on a school site and it is to be a partnership between the two parties. It is not a one-way street for either party, but a two-way street that both benefits. There should be a MOU in place that spells out how both parties will work with each other in order to have the students and families have the best chance of success.

(5) Your colleague makes some very valid and all-too-familiar points. CBOs often run on shoe-string budgets comprised of funding streams that can restrictively focus on specific needs and/or specific populations. That’s why CBOs tend to focus on those students eligible for Medicaid reclaiming and can’t expand their limited resources to “general populations”. Just like schools, their budgets don’t go that far. The description sounds like a CBO has been invited to come into the school rather than partner with the school to address barriers to learning. If, however, the CBO partners with the school to understand barriers of the entire student body, they are more likely to find ways to address needs that goes beyond Medicaid if their goals align with those of the school. For example, the CBO might be dedicated to serving high-risk youth (Medicaid eligible) and providing supports to youth that require early intervention services. These two types of supports could look very different but still achieve the goals for both the school and the CBO. Only a school and their CBO partner can figure out exactly what those services could be. The strict confidentiality concern mentioned can be, in and of itself, a barrier to supporting students. CBOs may be operating under HIPPA requirements or have their own policies that go above and beyond HIPPA. (See: https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html)
    Naturally, the school needs to understand the types of supports that individuals receive to prevent duplication and maximize limited resources. I believe this is an administrative level discussion that could include the district’s lawyer to determine the information that can and cannot be shared. I’m not as familiar with HIPPA but do know that FERPA has exceptions that allow the sharing of limited information in specific situations. My suggestion here is more about working at administrative levels to more clearly define confidentiality for all parties involved.
    Finally, I must admit that I am a bit confused by the description of the student support team. This Team sounds like a wonderful student focused coordination team that tracks individuals and works to support them. I understand that a student-focused team needs to know what programs and services exist but think that mapping resources for the purposes of meeting student needs is a job for a learning supports team. The Learning Support team reviews the data that pertain to the entire student population to identify barriers to learning at the systems level and set priorities for making changes to benefit students as a whole –– not at the individual level. The Learning support needs data from the student support team and may come to a similar conclusion regarding the Medicaid reclaiming concerns mentioned, for example. But it is their job to focus on what needs to be changed to meet student needs rather than focus on individual students that could benefit from a specific service.

(6) I agree with our colleague that CBO's are often operating in schools with a fee-for-service and clinical model that is not equipped or interested in the larger School MH approach. Many of those students who are eligible for Medi-cal probably do need MH therapy/counseling. And so do many others who aren't eligible for Medi-Cal. This just results in a patch-work, ad hoc, approach which is not coordinated with the school system and not addressing the real needs and concerns of establishing positive MH system. Beyond the therapy/counseling needs and model the school and students need an ongoing developmental, prevention, intervention, treatment approach.
    If CBOs are to be used, they need to share essential information on the students' "treatment" approach and not be an isolated entity that doesn't work in partnership with the school. The school, or Student and Learning Supports Professionals, is authorized to supervise these CBOs per the Ed Code Regs pertaining to PPS Credentials. Unfortunately the whole concept of SMH is too often not in operation, and as usual we are stressing mental disorders and overlooking positive learning and social-emotional development, prevention, early and timely intervention.

(7) This colleague and I match very well. I’ve had similar experiences and concerns. One school district formed a committee to try to figure out a confidentiality policy that would work among a) public school educators, b) county mental health counselors who had offices in various public school buildings, c) school resource (police) officers, and d) county social workers. I kept pushing “need to know” as an essential common component of confidentiality. Everybody seemed to agree things would be better if we all could talk to each other more fully. But nobody ever claimed to have the power to change their agency rules, which effectively prevented speaking more fully with the “others.” Some folks even seemed to enjoy the power that comes from “I know something you don’t know”!
    A school district concerned about lack of access to mental health counselors investigated funding sources and discovered their school psychologists could bill. But the record-keeping and billing rules were so burdensome and the threat of massive punishments for even relatively minor clerical errors convinced the district the benefits were not worth the risks.
    The county social workers liked the “wraparound” model, which involved several agencies at one, big meeting. It helped to come up with comprehensive plans but it took a lot of time just to match schedules so everybody could get there. It was even more difficult to get people together for a second “course correction” meeting.
    My personal conclusion is that the essential structure and organization of public schools contributes to this fracturing of services. Schools need to be designed from square one as a place to people with individual differences can connect with the services they need at their current level of development. That makes education, social work, mental health, addiction recovery, etc. parts of the intended program for all students, not just bolted-on after-thought services only for those who “qualify” due to the inability of the school to have anticipated and adjusted to their needs. I’ve wondered whether education for school staff demystifying mental health/mental illness, what treatment involves and what are reasonable goals of treatment would help.”

(8) When schools begin partnerships, they need to figure out how to support partners who take all insurances. Kaiser and Department of Defense are two key players in this model. For Kaiser, we have been working with their community liaison to access funds for services, so that students can benefit from the mental health supports. We have a partnership with the Department of Defense to provide services to those kids via telehealth or other support to assure those students can access the services. It takes a good school social worker to know all these resources, and it takes a good administrative team who knows what to do to assure MOA/MOU etc are in place for co-located services. We selected providers who were "school friendly" and we also have grant funds to subsidize mental health services until we can get all the bureaucratic stuff together.
    Best not to partner unless there are assurances that all students will benefit, and school system work should be able to get through the hoops for access. Sometimes its worth going for a grant. and being in the situation these folks are in, best to galvanize the school social workers who can assist with primary care and other community mental health folks who might assist or provide a family with 3 referrals that might assist.

Given all this, we decided to share the following Center resources as relvant in addressing the above challenges:

With respect to Confidentiality and Informed Consent concerns, see the range of resources from our Center and from others listed on the Center Quick Find -- https://smhp.psych.ucla.edu/qf/confid.htm . Here is a sample of Center resources you can access:

>Reframing the Confidentiality Dilemma to Work in Children's Best Interests
https://smhp.psych.ucla.edu/publications/reframing the confidentiality dilemma to work.pdf

>Confidentiality and Informed Consent (related to minors in agency collaborations)
https://smhp.psych.ucla.edu/pdfdocs/confid/confid.pdf

With respect to Memoranda of Agreement, see the Quick Find – https://smhp.psych.ucla.edu/qf/mou.htm . A sample of Center resources found there include:

>Want to Work With Schools? What is Involved in Successful Linkages?
https://smhp.psych.ucla.edu/publications/54 want to work with schools.pdf

>Making MOUs Meaningful
https://smhp.psych.ucla.edu/pdfdocs/practicenotes/makingmou.pdf

Please share your thoughts on all this.

Send your responses to Ltaylor@ucla.edu
______________________

Here's a response to the above from the field:

I completely understand the writers feedback. I myself had the similiar concerns when the School Based Health Clinic (SBHC) that was in my school setting began giving social worker services. My situation may have been unique has our clinic services students that required counseling supports to address non-educational concerns; having a medical eligibility was not a criteria. The students were required to become members of the clinic if they were not already part of the clinic. In developing a working relationship with the SBHC mental health provider, the school social worker and myself would meet with the clinician and developed a system of communication. A key component was to obtain copy of the release of information signed by the parents for our records. This eased the difficulty of having a HIPPA compliant release. It also allowed us to know which students were receiving counseling services through the clinic that we were not aware of. We often make referrals to the clinic for counseling supports when the matter is sensitive and the parents do not want the school staff to be aware or may not be having an educational impact but is having an impact to the family. The school based health clinics often work with staff that receive in school counseling supports to make sure that there is not a contridiction in what the student is hearing and also to verify what areas of concerns area being worked on. The clinics that I have worked with offer Trauma Focused CBITS, which is something that although we would love to spend the time to do. It is not logistically possible. At times, it is difficult not to become territorial in regards to the students that school employed mental health providers work with but in reality so many students require supports that there is enough for all. The key component with working with the SBHC's is to develop a dialogue and for individuals to be cognizant of their own personal biases when doing so.