Seattle SBHCs “Reaching for Excellence”

1. Seattle SBHCs“Reaching for Excellence” TJ Cosgrove – Public Health Seattle & King County

2. Seattle’s School-Based Health Centers • 14 SBHCs: 10 Comprehensive HS 4 Comprehensive MS • Public Health-Seattle & King County serves as program manager • Four additional health care organizations serve as SBHC “sponsors” • School District and City are key partners

3. Seattle’s School-Based Health Centers • Staffing: 1.0 FTE Mid-Level Practitioner (ARNP) 1.0 FTE MH Counselor 1.0 FTE Administrative Support • Middle schools flex .5 FTE ARNP into mental health and/or health education • Some sites offer “enhanced” services (health education, nutrition, massage therapy)

4. Seattle’s School-Based Health Centers Funding • Seattle’s Families and Education Levy • Partner Contribution • Billing (Medicaid, Take Charge) • National Philanthropic Organizations • Local Philanthropic Organizations • School District “in-kind”

5. Mental Health Services Prior to Caring for Kids Grant • SBHCs in transition from gateway to mental health services to provider of mental health services • Health care sponsors providing mental health services rather than subcontracting with community agencies • Reduction in resources for Medicaid eligible youth • Need to increase in-house skills, resources, and expertise to address the above trends

6. “Reaching for Excellence” Goals of the Project • Increase School-Based Health Center staffs’ ability to knowledgeably treat youth that have significant mental health issues • Improve interdisciplinary (mental health/physical health) coordination within the School-Based Health Center sites • Improve coordination with external agencies that provide psychiatric/mental health services

7. RFE Project Activities • Partnership with University of Washington / Children’s Hospital & Regional Medical Center Department of Child and Adolescent Psychiatry and Behavioral Sciences • 4 second-year fellows to provide psychiatric support and services • 1 University faculty member to serve as project lead • Formal trainings for all SBHC staff • 7 sites to receive 4 hours per month of on-site psychiatric support, includes phone/email consultation • Evaluation and Communication teams

8. On-Site Psychiatric Support • Consultation to SBHC mental health and medical staff • Direct patient care: evaluation, pharmaceutical management, and referral • Formal training of SBHC staff • Program planning and evaluation

9. Evaluation Plan • Surveys of clinic staff (including school nurses) and psychiatrists each spring for the first three years of the project • First year evaluation also included structured facilitated group interviews with clinic staff at each school and the psychiatrists • Year 2 and 3 surveys repeated some questions to monitor progress on program development issues and added new questions to target impact of formative changes made based on earlier surveys • Data review and analysis

10. Using Caring for Kids Data to Inform the Program and the Project • Encounter forms were not collecting meaningful data • Procedure and diagnosis coding included: CPT, DSM-IV, ICD-9, and “homegrown” codes – without consistent definitions • Encounter forms were revised along CPT and DSM definitions/guidelines (with exceptions) • Training was provided by UW fellows and faculty on use and application of DSM-IV and diagnosis of externalizing and internalizing disorders • On-site services emphasized interdisciplinary consultations

11. Program Improvements & Lessons Learned • More consistent, reliable and meaningful program data • For example: In the last quarter (Oct-Dec) of 2004, 40% of mental health visits had “No Diagnosis” as the primary diagnosis. In the last quarter of 2005, 6.5% of mental health visits had “No Diagnosis” as the primary diagnosis • Improved data revealed prevalence of emotional health diagnoses leading to University-led training in CBT and IPT

12. Program Improvements & Lessons Learned Based on the surveys, the model for providing psychiatric support evolved toward consultation, particularly interdisciplinary case consultations.

13. Program Improvements & Lessons Learned • As psychiatrist time was used more for consultation, staff became more satisfied with 4 hours per month • 93% of staff believed having on-site psychiatrist created more opportunities for interdisciplinary consultations and 87% felt the psychiatrist improved the quality of these consultations. • 73% believed that the on-site psychiatric support was the aspect of Reaching for Excellence that contributed most toward improving mental health services

14. Program Improvements & Lessons Learned • The picture that emerges is a steadily improving multidisciplinary approach to provide mental health services that maximizes the benefit of a small amount of psychiatrist time • Over the course of the project, improved data, enhanced skill sets, and a partnership with University expertise formulate professional development needs

15. Sustaining the Project • Continue each of the four fellows providing consultation and service to two school-based health centers • Each rotation includes two sites that are geographically proximate and, when possible, the pairing has included a high school and a middle school that “feeds” into the high school • SBHC sponsors will reallocate a portion of contract dollars from SBHCs into a contract with the to maintain these personnel and this model