Southwest District Health
Healthy Minds Partnership
Southwest District Health is a local health department in southwest Idaho, representing six counties that range from urban to frontier. The total population is approximately 270,000 and the southwest region is one of the poorest regions in the state with approximately 42% of households living below the poverty line or under the asset limited, income constrained, employed (ALICE) criteria as defined by the United Way. Increasingly, SWDH has been focusing not only on the delivery of essential services, coordination of the Women, Infants, and Children Program, and support of family planning services but also on behavioral health for the community we represent. Surveys of existing clients and outreach to community organizations for the Community Health Assessment have pointed to behavioral health as the top need for this region. The southwest region has under half the providers per capita as the average for the state (51 per 100,000 compared with 118 per 100,000). This is paired with a higher burden of illness for the region compared with the rest of the state. As a result, there is clearly a need for increased attention and support for behavioral health issues in the region.
Based on these data, SWDH decided to pursue a strategy to address behavioral health treatment access to catch behavioral health issues further upstream. Southwest District Health utilized an existing workgroup through the State Innovation Model (SIM) award body at the local level, the Behavioral Health Integration workgroup. The workgroup was asked to consider a more prevention-based strategy for addressing behavioral health issues in the area. The group, consisting of representatives from public health, primary care, specialty behavioral health, and Idaho Department of Health and Welfare, decided to look at partnering with schools to increase access to services in the provider shortage area. While SWDH was not the expert in this subject area, it served as a neutral convener among agencies who worked together to answer the question of how to assist schools with increasing access. Based on Medicaid rules within the state, it is extremely challenging for schools to deliver billable services on site for children. However, the group identified opportunities through smaller demonstrations to embed private behavioral health providers in the school setting and reduce the burden on the school while increasing opportunities for access. Again, SWDH served as the convener and project manager for this work, and approached a local school district about serving as the pilot site. After meeting with the school several times to determine needs and readiness, SWDH staff circled back to community organizations with expertise in this area to determine a plan for identifying a partner organization, addressing billing concerns, and drafting the partnership agreement. Southwest District Health also lead the effort to secure the support of several large local foundations who helped supplement the project management costs and provide funding for an evaluation and report out. This convening role allowed SWDH to connect experts and technical assistance to the community organization (i.e., school) for enhanced implementation.
As a result of this effort, two local schools were able to develop a novel agreement with a local behavioral health provider agency in the area to deliver 30 hours of services per week per school. Students who would have not otherwise had access to services due to time away from school, transportation barriers, and guardian work schedules can now receive much needed therapy. These services are sustainable and billable to both commercial payers and Medicaid. Both the schools and the agency are very satisfied with the services. Evaluation is currently underway to assess the impact on student clinical outcomes, attendance, classroom behavior, and academic performance. This work, as well as a developmental analysis performed by SWDH, will provide the foundation for a roadmapâ€ for implementation that will be delivered to schools and behavioral health agencies across the state to increase access not only for children in the southwest region but across Idaho. As a result, the objective of increasing access to behavioral health services for children in partnership with schools was not only met but exceeded as we were able to expand impact beyond our service area.
The key issue addressed by SWDH's promising practice is a lack of access to care compounded by increasing burden of illness. As previously described, the southwest region has a severe shortage of behavioral health providers but a higher level of burden of mental health conditions. While this issue is particularly significant in SWDH's service area, it is likely a concern for other LHDs, particularly those in rural and frontier areas. In fact, 85% of behavioral health provider shortage areas in the country are in rural or frontier communities (HHS, 2004). This points to a national issue in access to care for the communities we serve.
The target population for this work includes children across the state of Idaho with a need for behavioral health services. However, for the purposes of the demonstration, students at a local middle school and high school in the Nampa School District with behavioral health service needs were targeted. Nampa School District students are 70% white and 25% Hispanic. Across the entire district, 63% of students qualify for free or reduced lunch. At the middle school, 73% of students qualify for free or reduced lunch while at the high school it is 58%. The school district serves approximately 14,500 students and 1,401 or just under 10% qualify as homeless while 239 qualify as migrant (Nampa School District, 2017). No data currently exists on the total prevalence of mental illness and/or substance use at the school but using the NHANES (2014) estimate of 13% of children ages 8-15 years old experiencing a diagnosable mental illness it is reasonable to assume that at least 261 students at both schools have a diagnosable condition. This does not include situational behavioral disturbances. The established program has served over 70 students but that number will grow as the behavioral health agency increases capacity by expanding hours of service. As we teach other LHDs in the state how to do this work, the target population will expand. If this program reaches just one quarter of the 190,000 students in the state of Idaho, it will mean over 6,100 students served.
Previously, the issue of youth behavioral health services access was largely managed by the schools. However, the schools have very limited resources and bandwidth to address serious mental illness or therapy issues. As one counselor put it, We can only put out fires. We can't do anything to fire proofâ€. In addition, the Medicaid rules in Idaho make it prohibitively challenging for schools to act as a billable provider and schools are just not set-up to function as clinical service organizations. Previous solutions have also focused on pro-bono partnerships. While services have been well-received and have resulted in positive outcomes, they were not sustainable and could not possibly keep pace with the demand in schools. Finally, some agencies have started to partner with schools to deliver telehealth options to a small number of students. While this work has been somewhat successful, the volume has not been sufficient to drive scalable, durable business models.
This promising practice is an improvement upon existing efforts because it gives schools and behavioral health agencies implementation support, a demonstration of a successful model, and is sustainable with limited or no additional funding required. By leveraging existing community resources and experiences, it takes the onus off of the school and the behavioral health provider, who likely do not have experience or connections in the other sector, and allows them to rely on the local health district to provide project management. This work is innovative in that it positions the LHD to facilitate clinical-community linkages for youth behavioral health not just through introductions but as a key team member, assuming primary responsibilities for project management. It is also novel in the partnership with local philanthropy to expand the demonstrated model. We believe this project is new to the field of public health. Borrowing the concept of chief health strategist, it adds through the application to the youth behavioral health access issue and the project management function. We believe that this practice is an excellent demonstration of the power of public health and the new role it can assume in local communities.
The goal of the practice was to increase access to behavioral health services for children through partnership with local schools. A secondary goal was to increase the knowledge base in the state regarding the model to increase adoption and implementation.
In order to accomplish these goals, SWDH utilized an existing network of local partners invested in behavioral health solutions through the regional Behavioral Health Integration Workgroup. This workgroup includes the LHD, primary care, specialty behavioral health, and the Idaho Department of Health and Welfare. It is convened by SWDH through the SIM Award in the State of Idaho. The first step this group took was to identify existing models to increase access to behavioral health services for children. This included outreaching school districts across the region, other behavioral health providers, and the Idaho Department of Health and Welfare. The information gathered in this process indicated that previous efforts were either unsustainable for behavioral health agency due to ineffective billing arrangements or overly burdensome to schools who could not absorb the program design and management role into existing operations. However, there were smaller scale partnerships between schools and behavioral health agencies that had been successful in increasing access for a handful of students.
At this time, SWDH approached several local foundations about sponsoring the project. All foundations contacted for this purpose decided to support the project primarily for evaluation. A total of $3,656 was allocated for project management (staff time). Additional staff time has been funded by SWDH for a total of approximately $4,000. Around $10,000 was offered for evaluation but this money has not been utilized due to the low cost of data collection. In addition, the largest funder has offered in-house, in-kind support for graphic design, data analysis, and report writing.
Southwest District Health then proceeded to approach local schools regarding interest in participating in a demonstration to increase access to behavioral health services for their students on behalf of the workgroup. Several schools expressed interest but ultimately a school with a history of previous partnership to deliver services was chosen. The previous effort had failed due to administrative burden to the school but administrators were extremely interested in making something work and committed to their time, principal time, and counselor time to collaboratively design a program. We would like to note that all interested schools across the state will receive implementation support through the roadmap but only two sites were selected for the initial demonstration.
Once the pilot site was selected in January of 2017, SWDH staff scheduled initial meetings with the school and the behavioral health workgroup chair to discuss school needs and program design. It was decided that the school would target the fall of 2017 to start services on site. In addition, the school requested full, on-site services with a bilingual provider and family services available. With these requirements in mind, SWDH developed and distributed a request for partnershipsâ€. This was effective because it allowed SWDH to serve as the convener and connector as a neutral, trusted agency in the community. There was no accusation of unfair criteria or notification. In advance of interviews to select the behavioral health agency, SWDH helped the school frame key questions based on the crucial input of community partners through the behavioral health workgroup.
When the partner agency was selected, SWDH facilitated five planning meetings through the summer to design the agreement, plan implementation, and identify evaluation metrics. For these meetings, SWDH consulted the behavioral health workgroup regarding content experts and invited them to participate as appropriate. The results were phenomenal. In the first meeting, a content expert from a local behavioral health agency with school partner sites in Oregon agreed to send multiple versions of MOUs to work on. Southwest District Health assisted by combining existing MOUs and facilitating discussions back and forth between the school and the agency. The Medicaid agency for behavioral health in Idaho even joined a meeting to help verify billing procedures to assist the behavioral health practice. Finally, a competing behavioral health agency of the group that was selected was absolutely crucial in the course of these meetings, sharing key insights on working with schools on other project. The neutrality of SWDH played a key role in allowing this sharing to occur to ultimately deliver services to children. The trust in SWDH and the resultant willingness of partners to share allowed this work to succeed.
At the same time the planning work was occurring with the school, SWDH was working with the local foundations and the regional Institutional Review Board to develop and evaluation plan. This included a strategy and appropriate approvals for data collection. Southwest District Health also worked to collect data as a part of a developmental evaluation, noting what other agencies should pay attention to when they attempt to implement and what was essential to promoting a successful partnership.
This culminated in a start date for services of August 2017. Providers were on-site at both schools and had full schedules within one month of starting. Therefore, the program has been successful in its primary goal. In fact, the behavioral health agency is looking to move staff to full-time on the school partnership in the next several months. Other schools in the state have begun to express interest in this work. This points to a promising direction for the secondary goal of increasing adoption of the model across the state.
To this point, only qualitative data have been collected. However, initial feedback from the school and the agency are very promising. We have demonstrated the model is possible and sustainable. The objective to increase access to behavioral health services for students has been achieved as clinical services are now available at the two demonstration sites. The secondary objective is to increase the knowledge base and model adoption across the state.
A data collection plan for full evaluation is currently under review by the Boise State University Institutional Review Board. This includes a plan to review aggregated pre/post data for all students receiving services on the following metrics:
Academic performance (provided by the school district)
Attendance (provided by the school district)
Clinical outcomes (PHQ-9; provided by the behavioral health agency)
Behavioral disruptions (provided by the school district)
In addition, surveys will also be given to students, guardians, and teachers. These surveys will assess impact on access issues, satisfaction with the service, impact on student behavior, and effect on classroom environment and performance. These data will be finalized in a report no later than April 2018 and will be available for report at the 2018 NACCHO Conference.
The SWDH team and partners have learned that this model is possible and is sustainable. It is clear that the LHD is perfectly positioned to serve as a convener to address multi-sector issues. It is also apparent that SWDH did not need to have expertise in the field but instead needed a strong ability to navigate existing and emerging partnerships to better serve the school and the behavioral health agency. The SWDH did not perform a cost/benefit analysis but strongly believe that this work is cost-saving. If one considers the cost of the project management ($7,656) against the cost of a one-month inpatient stay to treat depression for just one child at a conservative estimate of $24,964 (taken from estimates in Stensland, 2012), it is clear that this practice is likely saving cost. As a result of this work, there is commitment from partners to not only continue the work but expand it. The SWDH team will work with the school district to develop a plan to implement in additional schools. In addition, many partners across the state have indicated interest in the roadmapâ€ to be published in Spring 2018. The SWDH team and behavioral health workgroup will continue to be a resource for communities looking to implement. In addition, the roadmapâ€ will be published to help support other schools and LHDs to engage in similar partnerships. It is crucial that this work continues to help the children of our communities thrive.
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