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Service Delivery Innovation Profile

Remote Assessment and Treatment via Telemedicine Combined With Onsite Case Management Enhance Access to Mental Health Services for Low-Income and Minority Students


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Snapshot

Summary

In collaboration with the Galveston Independent School District, the Teen Health Center of Galveston County, and several other community-based partners, the University of Texas Medical Branch provides remote mental health assessment and treatment services via videoconferencing technology and onsite case management to low-income, minority, and other students and parents in seven school-based primary care clinics in the Galveston Independent School District. The program is designed to overcome barriers to receiving timely mental health services, including poverty, social stigma, and transportation difficulties and aims to improve student mental health status and behavior. The program has improved access to needed mental health services in a population that has little means of accessing such services.

Evidence Rating (What is this?)

Suggestive: The current evidence consists of post-implementation data on the number of patients served, along with preliminary results from a more extensive evaluation that will provide pre- and post-implementation comparisons of key indicators, along with post-implementation data on program use, mental health status of participants over time, and user satisfaction.
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Developing Organizations

Ball High School, Galveston, TX; Central Middle School, Galveston, TX; Galveston Independent School District; Teen Health Center, Inc., Galveston, TX; University of Texas Medical Branch; Weis Middle School, Galveston, TX
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Date First Implemented

2006
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Patient Population

Age > Adolescent (13-18 years); Child (6-12 years); Vulnerable Populations > Mentally illend pp

Problem Addressed

An estimated one-fifth of U.S. children experience mental or behavioral problems, including substance abuse. The risk is higher among low-income and minority children, who are less likely to receive high-quality treatment. As a result, these conditions can strain family and other relationships and have a serious, long-lasting negative impact on the child's life.
  • High prevalence of mental disorders among children: Roughly 20 percent of children between the ages of 9 and 17 years are impaired to some degree by a mental disorder, including anxiety, mood, disruptive, and substance abuse disorders.1 Results from the 2001 to 2003 National Health Interview Survey suggest that 17 percent of children have experienced recent minor emotional and/or behavioral difficulties, whereas 5 percent have experienced recent definite or severe emotional and/or behavioral difficulties.2
  • Higher risk among the poor and minorities: Children in low-income families are more likely to experience emotional and behavioral difficulties,2 while racial minorities are less likely than non-Hispanic Whites to receive treatment for mental disorders and often receive lower-quality care.3 The Galveston Independent School District has a higher percentage of economically disadvantaged students (63.5 percent) than does the typical school district in Texas (54.9 percent). Furthermore, the city of Galveston has many minorities among its age 18 years and younger population (32.2 percent African American; 35.5 percent Hispanic; 27.9 percent White; 2.4 percent Asian; 1.5 percent other).4
  • Long-lasting negative impact: Untreated mental health disorders can lead to school failure, family conflicts, drug abuse, violence, and suicide5 (which is the fourth leading cause of death among youth aged 10 to 14 years3).

What They Did

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Description of the Innovative Activity

In collaboration with several community partners, the University of Texas Medical Branch provides remote mental health assessment and treatment services via videoconferencing technology and onsite case management to low-income, minority, and other students and parents in seven school-based primary care clinics in the Galveston Independent School District. The program's goal is to improve student mental health status and behavior, which is expected to lead to a reduction in student absenteeism, drug use, and violent behavior in the schools. Key components of this program are as follows:
  • Referral for services: Student may self-refer (i.e., walk in) to the program or be referred in writing or by telephone by school personnel throughout the district (e.g., teachers, school social workers, and school administrators), school-based Teen Health Clinics or other primary care providers, community-based counseling or social service organizations, the court system, or family members.
  • Convenient location and hours of operation: The program began in 2006, offering services in four school-based primary care clinics 5 days a week during school hours. As of October 2010, the program has expanded to seven school-based primary care clinics, with two additional sites in the planning stages. Services are available to all Galveston Independent School District students and their families free of charge.
  • Onsite case management and intake services: School-based caseworkers complete intake paperwork (e.g., registration and parental consent forms) with students and their parents, prioritize referrals, and assign cases to the clinicians based on level of care needed, clinician specialty, and clinician availability. Students with acute mental health issues usually receive immediate services or referrals to the hospital emergency department. In less serious cases, students make an appointment for a videoconferencing-enabled session with a child and adolescent psychiatrist or psychologist or they receive a referral to a community partner agency for counseling or other needed services. Caseworkers provide ongoing case management services, including coordination of services, transition in care between community-based providers, followup to see if students have complied with recommended services, appointment reminder calls to students and families, assistance with transportation when necessary and feasible, and other ongoing support.
  • Videoconferencing-enabled psychiatric consultation and counseling: The program conducts most psychiatric consultations and counseling services via videoconferencing-enabled sessions. With the assistance of portable videoconferencing equipment (including a large flat-screen monitor), students and their parents can see, hear, and interact with University of Texas Medical Branch child and adolescent psychiatrists or psychologists on a real-time basis. These sessions occur in a child and family-friendly clinical space. Videoconferencing is also sometimes used to supervise testing that is conducted by an onsite University of Texas resident or fellow.
  • Clinical services: Mental health services include treatment for depression, eating disorders, anxiety disorders, attention deficit hyperactivity disorder (ADHD), conduct disorders, and substance abuse. Treatment options include psychiatric consultation, family therapy, and individual counseling. Other services include academic counseling, ADHD and behavioral assessment, writing prescriptions for needed medications, and distributing low-cost medications. All mental and behavioral health specialists follow evidence-based clinical guidelines for the assessment and treatment of mental disorders.
  • Electronic medical records system: A Web-based electronic medical records system allows program staff to access student medical records from any location and for interdisciplinary consultation between each member of the treatment team.
  • Hotline and Web site: Students can obtain information and referrals 24 hours a day through a telephone hotline. Program case workers currently answer the hotline on an on-call basis. The program also provides a Web site access portal through which students, their families, and community partners can access resources and information.

Context of the Innovation

Established in 1891 in Galveston, the University of Texas Medical Branch is part of the University of Texas system, operating seven hospitals and numerous clinics, centers, and institutes, including schools of medicine and nursing. One of the nation's leaders in the field of telepsychiatry, the medical branch has been using videoconferencing technology to provide mental health services since 1999. The medical branch partnered on this project with Teen Health Center, Inc., a nonprofit organization providing free preventive and primary care to Galveston residents under the age of 23 years through five full-time and two part-time school-based clinics.

The impetus for this program arose from teacher and parent focus groups that identified several areas of concern regarding student mental health within the Galveston Independent School District. Ben G. Raimer, MD, a pediatrician and vice president for community outreach at the University of Texas Medical Branch, already had a good working relationship with the school district and Teen Health Centers, Inc. through their joint efforts to provide school-based primary health care. Recognizing the need for mental health services among underserved youth in the school district and the potential benefits of applying telepsychiatry in a school-based setting, Dr. Raimer approached Teen Health Center, Inc. about starting a telepsychiatry program within its school-based clinics. The initial goal was to close the gap in access to mental health services, improve mental health outcomes and to encourage community-based partnerships among the major academic health center in the area, the local mental health authority, community-based social service agencies, and the local school districts.

Did It Work?

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Results

Post-implementation data on the number of students served suggest that the program has enhanced access to needed mental health services in a diverse population that has little means of accessing such services. A comprehensive repeat measure evaluation of the program is ongoing.
  • Increasing numbers being served, suggesting enhanced access to care: During the first 6 months of operation, the program registered 20 new patients and 15 followup appointments; comparable figures during the first 6 months of the second year of operation were 61 and 116. Because most new patients had not received mental health services within the past year and were on average more disabled than many patients who seek inpatient treatment, it is highly likely that these students would not have received much-needed mental health services in the absence of this program. The total number of patient contacts in 2009 increased more than 640 percent (4,587 contacts as compared with 614 the previous year), illustrating how the program continues to increase access to care.
  • Diverse population served: The program continues to reach diverse patient populations (40 percent White non-Hispanic, 32 percent African-American, 27 percent Hispanic, and 1 percent Asian), despite a shift in demographics of Galveston post-Hurricane Ike.
  • Ongoing, comprehensive evaluation: More comprehensive evaluation efforts are currently under way to track the following: (1) mental health status over time, based on assessments conducted at the initial clinical appointment, 3 months, and 6 months (or at termination of treatment); (2) student and parent satisfaction (through surveys); (3) pre- and post-implementation teacher perceptions on school climate (also through surveys); and (4) overall school performance, including academic performance over time, attendance, and referrals to alternative education. As of October 2010, several notable outcomes and preliminary results from this evaluation include:
    • Students show a statistically significant reduction in symptom levels between the initial visit and the 3rd month visit.
    • Surveys indicate strong agreement by parents/guardians that their child is getting along better with family members (72 percent agree) and that their child is doing better in school (68 percent agree) as a result of services provided.
    • Surveys indicate no statistical difference between African-American and White, non-Hispanic parents' perception of care.

Evidence Rating (What is this?)

Suggestive: The current evidence consists of post-implementation data on the number of patients served, along with preliminary results from a more extensive evaluation that will provide pre- and post-implementation comparisons of key indicators, along with post-implementation data on program use, mental health status of participants over time, and user satisfaction.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Initial needs assessment: Parent and teacher concerns regarding student mental health prompted the University of Texas Medical Branch's Office of Community Outreach to convene a mental health task force in the fall of 2004, which conducted a community mental health needs assessment. This needs assessment identified the major problems facing Galveston Independent School District students and the potential barriers to receiving mental health services.
  • Protocol development: Program leaders developed a protocol for mental health consultations and evaluations before the program launched; this protocol has been (and will continue to be) revisited and adjusted as needed.
  • Pursuit of funding resources: The University of Texas Medical Branch applied for and received several grants to cover the cost of program startup and development.
  • Training: Teen Health Center, Inc. staff, mental health clinicians, and school personnel received up to 1 day of individualized training, as described below:
    • School-based clinic staff: The University of Texas Medical Branch's Clinical Technology School provided onsite training for nurse practitioners on use of the technology (including the videoconference system and electronic medical records) and on collaborating with psychiatric providers.
    • Psychiatrists and psychologists: The Medical Branch's Electronic Health Network provided system-specific training to each participating mental health clinician.
    • School personnel: The medical branch provided inservice training to faculty and administrators at each school. Topics of discussion included identifying the early signs of mental illness, collaborating with school-based clinic staff, and maintaining student confidentiality.
  • Addition of new sites: Initially operating out of two school-based clinics, the program eventually expanded to add five additional sites (across four school districts), with plans to add two more (updated October 2010). Several of the newer sites focus on providing services to younger students and their family units as an effort to promote early intervention and primary prevention in families without previous access to specialized care, and one of the newer sites is in the county juvenile justice facility.

Resources Used and Skills Needed

  • Staffing: Key staff for the program include two master's level social workers responsible for processing referrals, assigning cases to clinicians, and providing case management services for students and families; four University of Texas Medical Branch psychiatrists and one psychologist responsible for conducting mental health assessments and providing mental health services to students and families; one administrative assistant; and numerous technicians from the University of Texas Medical Branch Clinical Technology School.
  • Costs: The operating budget for the first year was $117,129 for two school-based clinics. The second-year budget increased significantly, to $251,504, to accommodate a projected increase in the volume of services provided and implementation of the program in a third school-based primary care clinic. Costs continue to increase as the program expands.
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Funding Sources

Robert Wood Johnson Foundation; Galveston Independent School District; Rockwell Fund, Inc.; The Mary Moody Northern Endowment; The Moody Foundation; Dr. Leon Bromberg Charitable Trust Fund; The Jamail Galveston Foundation; Harris and Eliza Kempner Fund
The project is supported by a $500,000 grant from Robert Wood Johnson Foundation and matching grants funds from six local sources. In early 2010, the Galveston Independent School District committed $350,000 for services to be provided during the current fiscal year.end fs

Tools and Other Resources

The ADHD Rating Scale IV is used to diagnose and assess treatment response for Attention-Deficit Hyperactivity Disorder (ADHD). See http://www.guilford.com/cgi-bin/cartscript.cgi?page=pr/dupaul2.htm&dir=pp/adhdr&cart_id=74356.3109 for more information on this instrument.

The CES-D Scale is used to assess depression symptoms. See http://apm.sagepub.com/cgi/content/abstract/1/3/385 for more information on this instrument.

The Eyberg Child Behavior Inventory is used to assess number and frequency of behavioral problems of students reported by parents. See http://vinst.umdnj.edu/VAID/TestReport.asp?Code=ECBI for more information on this instrument.

The Pediatric Symptom Check List (PSC and Y-PSC) is used to assess anxiety symptoms. See http://www.nasbhc.org/atf/cf/%7BCD9949F2-2761-42FB-BC7A-CEE165C701D9%7D/mh_psc_youth.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.) for more information on this instrument.

Adoption Considerations

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Getting Started with This Innovation

  • Secure buy-in of key stakeholders: Participating school and district personnel need to be engaged and committed to the success of the program. In addition, the program's success depends on the availability of dedicated primary and mental health professionals who are willing to collaborate to ensure continuity of care for students and their families.
  • Formalize partner roles and responsibilities: Clearly outlining the roles and responsibilities of all partners is crucial to the effective, efficient, and successful implementation of the program. Use of memorandums of agreement should be seriously considered.
  • Emphasize the mutual benefits of participation: Each of the partners not only make valuable contributions to the program, but will also benefit from it. In the case of this program, the Galveston Independent School District and its participating schools benefit from the convenient, no cost, and much-needed mental health services that are provided to students. The University of Texas Medical Branch Department of Psychiatry and Behavioral Sciences benefits from the opportunity to develop and test new best practices and from research efforts that stem from their participation in the program. In addition, the medical branch will soon be using the program to provide learning opportunities to social work interns and psychiatry fellows.
  • Educate and engage the community: It is important to educate the community to help overcome the stigma associated with receiving mental health services. Creative strategies may be required, including outreach to public housing units and the judicial system.

Sustaining This Innovation

  • Engage in ongoing communication and collaboration: Community partners need to be involved not only during program planning and implementation, but also as the program matures and evolves.
  • Actively pursue alternative funding sources: Because grant funding is usually time-limited, active pursuit of alternative funding sources, including third-party reimbursement, should be considered. Documenting the cost savings, increased revenue, and results regarding the number of children served will engage the school board, which can lead to funding opportunities (updated October 2010). Actively collaborate with community partners as well to apply for federal and state grants.
  • Expect to add resources: Caseworkers and clinicians realized during the first 2 years of operation that the majority of students and families being served had not previously received mental health services and were more disabled than the typical patient who seeks inpatient treatment. The population, therefore, required more intensive intervention, advocacy, and coordination of services than originally anticipated. As a result, additional resources were required to serve these clients appropriately.
  • Adjust technology as needed: Problems can occur as the program is integrated into the existing technological infrastructure of schools. For example, firewalls designed to protect a school's computer network may need to be adjusted to enable videoconferencing capabilities.

More Information

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Contact the Innovator

Ben G. Raimer, MD
Senior Vice President, Health Policy & Legislative Branch
University of Texas Medical Branch at Galveston
301 University Boulevard
Galveston, TX 77555-0916
Phone: (409) 747-2789
Fax: (409) 747-2795
E-mail: bgraimer@utmb.edu

Innovator Disclosures

Dr. Raimer has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Bryant B. Telepsychiatry gets good reception with Texas high school students. Psychiatr News. 2007;42(5):22. Available at: http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=110754

Footnotes

1 U.S. Department of Health and Human Services. Mental health: a report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 1999.
2 Center for Mental Health Services. Mental health, United States, 2004. Manderscheid RW, Berry JT, eds. DHHS Pub No. (SMA)-06-4195. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2006. Available at: http://store.samhsa.gov/product/SMA06-4195
3 New Freedom Commission on Mental Health. Achieving the promise: transforming mental health care in America. Final Report. DHHS Pub. No. SMA-03-3832. Rockville, MD: Department of Health and Human Services; 2003.
5 National Mental Health Information Center. Child and adolescent mental health. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2007.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: June 09, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: August 15, 2010.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.