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Service Delivery Innovation Profile

School-Based Health Centers Enhance Access to Mental Health Services for Adolescents, Particularly African-American and Hispanic Males


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Snapshot

Summary

In addition to standard primary care services, Connecticut’s 78 school-based health centers offer a broad array of confidential mental health services to elementary, middle, and high school students, including one-on-one, family, and group counseling. Easy-to-access services are co-located with traditional primary and acute medical services so as to reduce the stigma associated with accessing them. All mental health care adheres to State-developed standards related to staffing and the types of services offered. The school-based centers have enhanced access to mental health services and generated high levels of satisfaction for students (particularly African-American and Hispanic males), and have led to less missed class time.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on use of mental health services by students, along with feedback from adolescents on the quality, timeliness, and value of those services and comparisons to other published data.
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Developing Organizations

Connecticut Association of School Based Health Centers; Connecticut Department of Public Health
The Connecticut Department of Public Health
The Connecticut Association of School Based Health Centersend do

Use By Other Organizations

A handful of other states implemented an integrated model of medical and mental health services at school-based centers through the Robert Wood Johnson Foundation grant program. Those states included: Colorado, Maryland, New York, North Carolina, Oregon, Rhode Island, and Vermont.

Date First Implemented

1994
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Patient Population

The racial breakdown of adolescents who received services at a school-based health center between 2006 and 2009 (the most recent data available) was 34 percent white, 32 percent African American, 13 percent Hispanic, 3 percent Asian, 5 percent other, and 13 percent unknown.Age > Adolescent (13-18 years); Race and Ethnicity > Black or african american; Hispanic/latino-latina; Gender > Male; Vulnerable Populations > Mentally illend pp

Problem Addressed

Many adolescents have untreated mental health issues, particularly racial and ethnic minorities who face multiple barriers to accessing care. Even when they do seek treatment, adolescents often quit after just a few sessions, with this problem also being more prevalent in minorities.
  • Untreated mental health issues, especially among minorities: In 2008, 2 million youth between the ages of 12 and 17 (representing 8.3 percent of the total population in this age range) had a major, depressive event in the past year, yet only a little more than one-third of them (37.7 percent) received treatment.1
  • Especially for minorities: This problem is particularly acute among racial and ethnic minorities; for example, African-American and Hispanic/Latino youth are only one-half as likely to initiate care for a mental health issue than their white peers.2
  • Multiple barriers to accessing care: African-American adolescent males confront multiple barriers to accessing care, including a lack of transportation, lack of health insurance, and financial barriers.3
  • Failure to continue with treatment once initiated: When racial and ethnic minorities do access care, they often discontinue treatment. For example, African-American adolescents were twice as likely to quit after two sessions with a mental health provider than their white peers.4
  • Urban poverty prevalent in Connecticut: Although Connecticut had the highest per-capita income of any state in the United States in 2011 ($57,902),5 poverty is prevalent in urban areas. The percentage of youth living under the Federal poverty level was 39.9 percent in Bridgeport, 47.9 percent in Hartford, 41.4 percent in New Haven, 34.5 percent in Waterbury, and 17.5 percent in Stamford.6

What They Did

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Description of the Innovative Activity

In addition to standard primary care services, Connecticut’s 78 school-based health centers offer a broad array of confidential mental health services to elementary, middle, and high school students, including one-on-one, family, and group counseling. Easy-to-access services are co-located with primary care and acute medical services so as to reduce the stigma associated with accessing them. All mental health care adheres to State-developed standards related to staffing and the types of services offered. Key program elements include the following:
  • Co-located services to reduce stigma: All urban school districts in Connecticut have onsite, school-based health centers that offer services without any out-of-pocket expenses. In addition to traditional acute and preventive medical care, the centers offer an array of onsite mental health services. (See bullet below for a description of these services.) Locating mental health services in the same facility helps to reduce the stigma associated with seeking help for behavioral issues because students are less likely to feel embarrassed coming to a combined facility.
  • Easy, flexible access points: Before a student can use any service at a school-based center, parents of minors must complete a written enrollment form. Students 18 and older can enroll themselves. Between 2006 and 2009 (the most recent data available), more than one-half (52 percent) of all eligible adolescent students had enrolled in a center. Enrolled students can easily access mental health services by dropping in or scheduling an appointment. In some cases, they may be referred by a member of the health center or school staff, including school nurses, social workers, or psychologists. Parents may request services for their child, or enrolled students may self-refer.
  • Confidential mental health services based on State standards: Adhering to Connecticut Department of Public Health standards, each center has a licensed therapist with a master’s degree and a background in child and adolescent health who offers individual, group, and family counseling; crisis management services; and mental health education. The therapists treat the whole spectrum of mental health and learning disorders, ranging from episodic problems (e.g., a new student facing challenges in assimilating to the school environment) to long-term issues such as autism, attention deficit hyperactivity disorder, or bipolar disorder. All services are confidential, and the therapist explains the rules governing the confidentiality of services carefully whenever a student accesses mental health services at the center for the first time. The emphasis on confidentiality is particularly important for establishing trust between therapists (the majority of whom are white women) and students from diverse backgrounds (such as African-American and Latino adolescent males).
  • Referrals for medication management: The therapist can provide a referral to a community-based physician for the evaluation and management of psychiatric medications.

Context of the Innovation

Schools in Connecticut have had in-house school-based health centers since 1989, with school-based health centers first being opened in high schools and then expanded to elementary and middle schools. The Connecticut Department of Public Health develops regulations and manages programs to ensure the health of the state’s residents and licenses each health center as an outpatient clinic or hospital satellite. Each center must be sponsored by a local organization, such as a hospital, federally qualified health center, not-for-profit agency, local health department, or school district. The sponsoring organization either provides the services, or in the case of a school district, subcontracts with a local health care organization to do so.

Before adoption of this program, the 29 school-based centers in existence at the time varied significantly in terms of services offered and how they were funded, and most did not offer mental health services. Recognizing the need for more uniform and comprehensive services (including mental health care), leaders of the Department of Public Health in 1994 applied for and secured a series of three grants, totaling $2.2 million from the Robert Wood Johnson Foundation’s national program, Making the Grade: State and Local Partnerships to Establish School-Based Health Centers. These funds helped Connecticut and other states implement a comprehensive, integrated model of medical and mental health services at school-based centers.

Did It Work?

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Results

The school-based health centers have enhanced access to mental health services and generated high levels of satisfaction (particularly well-documented among African-American and Hispanic males), and have led to less missed class time.
  • Enhanced access to mental health services: Between 2006 and 2009, 16,700 adolescents visited a center at least once during each of those years, with the average user visiting 4.8 times a year. Mental health services were the most frequently used services in the centers, responsible for roughly one-third (32 percent) of all visits.
  • Particularly for African-American and Hispanic males: During the 2007–2008 and 2008–2009 school years, 1,130 Hispanic or African-American adolescents received mental health services at a school-based center, with each visiting an average of 13.6 times over this time period. In a community setting, African-American youth are twice as likely as white youth to quit after only two visits, suggesting that the school-based mental health services better met the needs of African-American and Hispanic adolescent males.
  • Less missed class time: The vast majority (96.7 percent) of students using the school-based centers (either the medical or mental health services) return to class the same day, so they miss less school than if they had to access such services elsewhere in the community.
  • High satisfaction among African-American and Hispanic males: Interviews and focus groups with 22 Hispanic and African-American adolescent males from four communities demonstrate high levels of satisfaction with the mental health services, as evidenced by the feedback below:
    • Services that address their problems: Students reported learning how to better manage anger; relationships; and societal issues, such as pressure to conform to racial stereotypes or to engage in risky behaviors.
    • Quick, nonjudgmental, culturally sensitive service: The students reported that therapists responded quickly when they needed assistance with an immediate problem, helping them avert possible negative consequences. Students also found therapists to be nonjudgmental and culturally sensitive to the issues young African-American and Hispanic males grapple with every day.
    • Positive impact on performance: Some students felt that the mental health services had a positive impact on their grades and overall performance at school.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on use of mental health services by students, along with feedback from adolescents on the quality, timeliness, and value of those services and comparisons to other published data.

How They Did It

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Planning and Development Process

  • Developing infrastructure to incorporate mental health services: The Department of Public Health created a program office, the School and Primary Health Unit, and a State-level, interagency coordinating committee to develop the program, including standards for mental health services. The interagency committee included representatives from the departments of public health, education, correction, and social services.
  • Negotiating contracts for mental health services: Beginning in 1996, officials from the School and Primary Health Unit worked with local school-based health centers to negotiate contracts with Connecticut’s Health Care for Uninsured Kids and Youth (HUSKY), which includes Medicaid and the Children’s Health Insurance Program.
  • Developing political support for integrated mental health services: The Connecticut Association of School Based Health Centers created its first comprehensive public relations initiative in 1996 to build support for the centers among State legislators and parents in local communities. For example, the Association created press kits, brochures, and tabletop displays to describe the medical and mental health services newly offered at school-based health centers.
  • Securing buy-in from local schools: The mental health services within school-based health centers were designed to complement—not supplant—the services provided by schools’ existing nurses, social workers, and psychologists. Before integrating mental health services into school-based centers, program leaders met with school superintendents, principals, and school staff (e.g., social workers and psychologists) to explain the program and win their support.

Resources Used and Skills Needed

  • Staffing: A licensed, master's degree–level clinician provides the mental health services at each center, working an average of 32.7 hours per week. In Connecticut schools, most of these clinicians are white women between the ages of 30 and 60. Other center-based staff are not directly involved in the provision of mental health services, including a nurse practitioner or physician’s assistant, data entry clerk, center administrator, and medical director (located either onsite or in an easily accessible offsite location). The part-time versus full-time status of the staff varies by location.
  • Costs: The average budget for a school-based health center is $260,000. An estimate of the portion of the budget devoted to mental health services was not available, but staff costs are the primary component.
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Funding Sources

Connecticut Department of Public Health; Connecticut Husky Health
Public and private insurance covers the cost of mental health services for some patients. HUSKY Health, which includes both Medicaid and the Children’s Health Insurance Program, covers approximately one-half of all students. Private insurance covers an additional 26 percent; a growing number of the school-based centers have entered into contracts with private insurers in the last few years. The remaining students do not have insurance. To offset the costs of school-based mental health and medical care for these students, the Connecticut Department of Public Health funds roughly one-half of each center’s annual expenses through a line item in its budget. Private philanthropy, including the United Way, provides supplemental funding in the local communities.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Encourage therapists to participate in daily school life: To earn the trust of school employees and students, the therapist and other mental health providers should be visible in the halls, front office, and cafeteria, and should participate in parents’ nights and other school functions.
  • Be sensitive to existing staff concerns about job security: Reassure existing social workers and psychologists that their jobs will not be eliminated after the school-based health center begins offering mental health services. The school-based health center complements existing school health services but does not replace them.

Sustaining This Innovation

  • Encourage therapists to reassure students about confidentiality: Adolescents are concerned about protecting their privacy, so therapists should regularly remind students about the strict confidentiality rules governing counseling sessions.
  • Continue to advocate for support of mental health services: To ensure that the mental health needs of disadvantaged students remain a priority with State policymakers, consider creation of an advocacy organization to oversee research on the impact of mental health services on utilization of other health services and on academic performance and other metrics of student performance and well-being. This organization can also sponsor educational seminars and conferences for key stakeholders, including policymakers.
  • Seek reliable sources of financing: In addition to lobbying State government and securing contracts with Medicaid, the Children’s Health Insurance Program, and private insurers, solicit funds from foundations and other philanthropic sources that might be interested in supporting the provision of mental health services to uninsured students.

Use By Other Organizations

A handful of other states implemented an integrated model of medical and mental health services at school-based centers through the Robert Wood Johnson Foundation grant program. Those states included: Colorado, Maryland, New York, North Carolina, Oregon, Rhode Island, and Vermont.

More Information

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Contact the Innovator

Jesse White-Fresé
Executive Director
Connecticut Association of School Based Health Centers
P.O. Box 771
North Haven, CT 06473
(203) 230-9976
E-mail: jesse@ctschoolhealth.org

Innovator Disclosures

Ms. White-Fresé reported having no financial interests or business/professional affiliations relevant to the work described in this profile other than the funders listed in the Funding Section.

References/Related Articles

The Connecticut Association of School Based Health Centers Web site is available at http://www.ctschoolhealth.org/.

Two Robert Wood Johnson Foundation reports summarizing Connecticut’s expansion of its school-based health centers are available at the following links:

Footnotes

1 2008 National Survey on Drug Use and Health: national findings. Rockville (MD): U.S. Department of Health and Human Services. 2009. NSDUH Series H-36, HHS Publication No. SMA 09-4434. Available at: http://www.samhsa.gov/data/NSDUH.aspx.
2 Le Cook B, Barry C, Busch S. Racial/ethnic disparities trends in children’s mental health care access and expenditures from 2002 to 2007. Health Serv Res. 2013;48(1):129-49. [PubMed]
3 Xanthos C. The secret epidemic: exploring the mental health crisis affecting adolescent African-American males. Atlanta (GA): Morehouse School of Medicine. Available at: http://www.academia.edu/171493
/The_Secret_Epidemic_Exploring_the_Mental_Health_Crisis_Affecting_Adolescent_African-American_Males
.
4 Cuffe S, Waller J, Cuccaro M, et al. Race and gender differences in the treatment of psychiatric disorders in young adolescents. J Am Acad Child Adolesc Psychiatry. 1995;34(11):1536-43. [PubMed]
5 Personal income summary: per capita personal income. Washington: U.S. Department of Commerce Bureau of Economic Analysis. 2012. Available at: http://www.bea.gov/newsreleases/regional/spi/sqpi_newsrelease.htm.
6 Poverty, median income, and health insurance in Connecticut: summary of 2011 American Community Survey Census data. New Haven (CT): Connecticut Voices for Children. 2012. Available at: http://www.ctvoices.org/sites/default/files/econ12censuspovertyacs.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
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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: March 27, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 11, 2014.
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.