Schools are more than places to learn — they can be essential gateways to mental health care. We look at how school-based health centers are expanding behavioral health services for children served by Nationwide Children’s and Nemours Children’s Health, drawing on promising models highlighted in a new issue brief from the Nemours Children’s National Office of Policy and Prevention.
This is part one of a two-part series on improving access to pediatric mental health care. Part two will explore how telehealth and early relational health models help children thrive.
Featuring:
Daniella Gratale, MA, Associate Vice President, Federal Affairs, Nemours Children’s Health
Hannah Wagner, MPP, Senior Advisor, Policy Development and Partnership, Nemours Children’s Health
Mary Kay Irwin, EdD, Senior Director, School-Based Health, Nationwide Children’s Hospital
Jason E. Boye, PhD, ABPP, Clinical Director of School-Based Behavioral Health, Clinical Population Health Informatics Advisor, Nemours Children’s Health, and Clinical Associate Professor of Pediatrics, Thomas Jefferson University
Host/Producer: Carol Vassar
Announcer:
Welcome to Well Beyond Medicine, the world’s top-ranked Children’s health podcast produced by Nemours Children’s Health. Subscribe on any platform at nemourswellbeyond.org or find us on YouTube.
Carol Vassar, podcast host/producer:
Each week, we’ll be joined by innovators and experts from around the world, exploring anything and everything related to the 85% of child health impacts that occur outside the doctor’s office. I’m your host, Carol Vassar. And now that you are here, let’s go.
MUSIC:
Let’s go, oh, oh. Well Beyond Medicine.
Carol Vassar, podcast host/producer:
Hi, everyone. It’s another two-part episode of the Nemours Well Beyond Medicine Podcast. This time, we’re going to explore the topic of access, specifically access to mental health services for children. And the examples we’re highlighting in this episode and the one to come to us by way of an issue brief from the Nemours National Office.
Here from that office to introduce us to the brief are Daniella Gratale, Associate Vice President of Federal Affairs for Nemours Children’s Health, and Hannah Wagner, Senior Advisor for Policy Development and Partnerships at Nemours. Daniella, I’m going to start with you. Can you tell us a little bit about the origins of this project and about the project itself?
Daniella Gratale, MA, Nemours Children’s Health:
Sure. Thank you so much, Carol, for having us for this important discussion. So our national office has been working on the issue of mental health for a long time now, and we’ve really been thinking about, from a policy perspective and from the perspective of how we can highlight models, what can we do and what value can we add.
So we started by talking to our own psychologists, clinicians, our patient families. And because of where we sit at the national level, we’re also able to hear from experts and providers across the nation. And we’ve been doing this work for years, really wanted to think about how do we provide a platform then to share what we’re learning.
So a couple years back, we had done a family roundtable with then Secretary Becerra, some Delaware federal and state leaders. A year after that, we then convened school health leaders, and foundations, and some policy leaders as well in addition to families, of course, to talk about school-based mental health models and how can they help provide access.
And then all along, we’d been advocating before Congress working on the Bipartisan Saver Communities Act. And then for this project, really wanted to say, “Okay. What have we learned? How do we synthesize that and put it into what became a policy brief that pulls together key themes from these models and makes some recommendations for policymakers and funders about how they can continue to move the needle forward?”
Carol Vassar, podcast host/producer:
So this paper is just chock-full of great information. And as you mentioned, Daniella, you did look at programs from across the nation. All of which aim to address children’s mental health concerns early to prevent them from escalating. Hannah, I want to go to you. What were the key approaches you saw across all of the models that you looked at and specifically the ones you write about?
Hannah Wagner, MPP, Nemours Children’s Health:
Sure. So, as you mentioned, we looked at programs and models from across the country, and we really wanted to hone in on common approaches across all of these models. And some of the models that we looked at take a few of these approaches. Some one, some up to three. So the first approach that we really took a deep dive into was promoting resilience and long-term wellbeing through what we call early relational health. So what does that mean?
Early relational health is really helping young children and their caregivers develop really strong healthy relationships, and these relationships set the foundation for them to grow up healthy and well. And a lot of evidence shows that these healthy relationships or early relational health helps develop resiliency, and that can improve mental and physical health outcomes throughout the lifespan of the child.
So the second approach that we looked at was increasing access to mental health care and particularly, in terms of supporting early intervention. So that means catching a mental health concern before it escalates into something more serious. And as you mentioned, Carol, that’s the topic of the podcast series that we’re doing today.
Carol Vassar, podcast host/producer:
Mm-hmm.
Hannah Wagner, MPP, Nemours Children’s Health:
So what we look at in terms of access is, really, how can we make mental health services more convenient for children and families to access. So that often means bringing these services to where children and families spend a lot of their time. So that can be at school in the primary care setting, especially for young kids who are visiting the pediatrician’s office many times a year for the first few years of life or introducing telehealth, which kids and families can take these calls from home, or the car, or wherever is convenient. We see it all.
And then the third approach that we look at is implementing team-based multidisciplinary care to address children’s holistic needs. So, as we know, kids have relational, developmental, physical, mental health needs, and all of these are tied together. So team-based care really helps the providers to work together at the top of their license to work on all of the issues that may be influencing a young person’s mental health.
Carol Vassar, podcast host/producer:
Well, Daniella, Hannah, we’re going to get right to it right now, look at some of that wraparound services that are available within the school-based health centers with experts right now from Nationwide Children’s and Nemours Children’s Health. Stay with us.
With me right now are Dr. Mary Kay Irwin. She is Senior Director for School-Based Health at Nationwide Children’s Hospital in Columbus, Ohio. Also, here, Dr. Jason Boye, Clinical Director of School-Based Behavioral Health at Nemours Children’s Health. He’s also a clinical associate professor of pediatrics at Thomas Jefferson University in Philadelphia. I’m going to ask a question of each of you. I think, Dr. Irwin, I’m going to go to you first. Why are schools a great front door for getting to the kids who need pediatric mental health services?
Mary Kay Irwin, EdD, Nationwide Children’s:
There’s so many answers to that question, but I would say schools are wonderful sites of care for reaching those children who are disconnected and have a hard time seeking clinical care between the hours of 9:00 and 4:00. So we’re trying to reduce barriers, so it’s access for all and doing that at a place in which children routinely show up, and can take a school bus, and not rely on any other source of transportation is our first reason for bringing care to schools.
Another reason that we love to bring mental health services to schools is that it’s really helpful to be delivering care in the environment in which the kid is in. So sometimes school is a trigger, and when you’re right there in the school and can observe the school environment and also collaborate with all the other professionals working with that child, we see outcomes improve. So we really enjoy being a part of the child’s environment in addition to leveraging schools to reduce barriers such as transportation.
Carol Vassar, podcast host/producer:
Dr. Irwin, provide us with the architecture of nationwide school health services. How do mobile care and school-based health centers really fit into that scenario? And how do you decide how much treatment occurs in the school?
Mary Kay Irwin, EdD, Nationwide Children’s:
So at Nationwide Children’s, we have a very large behavioral health infrastructure. So school health is a very small piece of the larger Nationwide Children’s Behavioral Health structure, but I’ll speak just to the school health piece. So our framework really starts first with identifying pockets where we know there are preponderance of children who we can tell are not routinely accessing the doctor.
So we take, oftentimes, a look at primary care utilization as a first indicator for that, acknowledging that the primary care provider is supposed to be the child’s quarterback, taking care of the whole wellness and working with each individual specialist that may be working with that child. It’s just one indication to let us know where we should double down with school services.
And then what we do is we build a whole child framework to intentionally embed our services in collaboration with schools. I don’t know any school right now that is not trying to provide some level of wraparound services to the children and the families they aim to serve because there’s hardly anyone coming to school anymore that’s just there for arithmetic and language. Right? They bring their whole selves, and so schools are trying to figure out how we address all the needs that children bring to school. So what we do is we layer inner services into the school’s already existing, whether they call it whole child wraparound services. The goal being to mitigate gaps and not duplicate, right?
Carol Vassar, podcast host/producer:
Mm.
Mary Kay Irwin, EdD, Nationwide Children’s:
So when we go into a school, it’s, “Who do you already have here? If you already have a therapist from a community behavioral health agency and that’s working well for you, fantastic. We don’t need to bring that service, right? What are the gaps?” So what we do is we start with primary care as the anchor. And so we have 20 school-based health centers, and so that is primary care, comprehensive primary care services. We have two mobile units, and then we have a whole host of specialty services, behavioral health things for kids with high-risk asthma, and diabetes, and mobility challenges. Many things that are less relevant to the mental health part of this conversation. So it’s an extensive program that we embed into schools. And as I mentioned, we are really trying to become the medical home for those who do not have a provider.
So we do all the traditional things you would have done that a primary care provider would do, including screening for mental health concerns. So we follow the AAP guidelines, and when a young person comes to us for a sports physical, we do a comprehensive well visit and also, spend the time to make sure that that athlete isn’t silently suffering from depression, as an example.
And then our primary care providers are trained in primary care mental health, which means that they are trained to do the diagnosis and medication management for ADHD, anxiety, depression. Right? And then we have a whole infrastructure that we build out from there. So our behavioral-health-specific services that we offer if needed, right? If a community behavioral health agency isn’t already doing it, we offer prevention programs. We also have the Kids’ Mental Health Foundation, which is a resource for teachers, parents, and children, where they can download resources, participate in webinars, things of that nature.
We provide group therapy and also, individual therapy in the school setting. And then all the primary care providers offer primary care, mental health. When the mental health issues are beyond the scope of a straightforward case that a primary care provider is comfortable managing, then we offer telepsychiatry right through the school-based health center. So that is a high-level overview of the nationwide school health program.
Carol Vassar, podcast host/producer:
High-level, but very comprehensive obviously, and it’s great. I think one of the things that parents must like about this is that they don’t have to leave work, they don’t have to leave children, other children, find babysitters for other children to attend to that child, to take them to a doctor’s office, to an appointment. They can get that right in the school. Dr. Boye, briefly outline Nemours Delaware school-based health centers in terms specifically in provision of behavioral health services.
Jason E. Boye, PhD, Nemours Children’s Health:
Sure. Absolutely. So similarly to Nationwide, we have an array of behavioral health services through Nemours Children’s Health, and our school-based health centers is one service line of our broader behavioral health services. We are in 17, going on 18 schools within the state of Delaware, spanning from early education centers all the way through middle school students, so grade eight. We provide both physical and behavioral health services following very similar model with primary care style services without taking over as the primary care provider or the medical home for the student.
Our behavioral health services. We do conduct screenings for all students who enroll in our school-based health center. The type of behavioral health screening looks different based on the age of the student. When we are providing intervention, we are typically providing more of a short-term intervention model for behavioral health services, utilizing a flexible eight-session model of intervention within our schools.
We certainly want to make sure that we are providing the right level of care for the student, ensuring that we’re able to provide access to other students at the school, and also, trying to utilize some of the other behavioral health supports that are in the school. So, for example, if I’ve met with a student for eight individual therapy sessions and we’ve made a lot of progress, can I now help the student get connected to a group that is ongoing at the school where additional and different behavioral health services are being implemented, and I can open access for that individual treatment for another student within the school.
Carol Vassar, podcast host/producer:
In terms of behavioral health, it sounds like primary care is really the center of both of these models referring out to behavioral health. But what if the teacher notices, or another parent notices, or even another student notices that a child is not quite themselves and might benefit from the behavioral health services available at the school-based health center. How would that student be referred, Dr. Boye.
Jason E. Boye, PhD, Nemours Children’s Health:
So we accept referrals from a multitude of individuals, and so families can certainly reach out and request behavioral health services themselves through the school, the school administrators, principals, school psychologists, school counselors can refer students. What we really encourage from the school perspective is ensuring that that school team is aligned, that this is the type of behavioral health service that we’re looking for for this student.
And then we start every referral with a consultation to better understand presenting concerns, history, and make appropriate treatment recommendations. And sometimes that’s evaluation to open the door for a mental health diagnosis, which might provide different access to supports within the school, or opening the door for medication management and medication consultation. And other times, it is providing more of that individual or family-based therapy within the schools. But parents, students, themselves, school staff, can refer to our services for behavioral health.
Carol Vassar, podcast host/producer:
Dr. Irwin, is it similar at Nationwide?
Mary Kay Irwin, EdD, Nationwide Children’s:
It is. In fact, we also facilitate in a lot of schools, too many to even count, the Signs of Suicide program, which we’re really trying to create a culture of awareness around, Carol, what you were mentioning, which is when someone seems off, like everyone noticing, and how to get help, and what is a trusted adult. But officially, yes, we accept referrals from all the same sources Dr. Boye mentioned, and parents can call in.
The only thing, I guess, I would say differently is we also make sure that we… and you probably do this too, Dr. Boye, check in with athletic trainers and coaches, because oftentimes, children will… That might be their trusted adult, to make sure that those tied to the school know who we are, how to access us. And then also, when we have an arrangement where we’re working in a school and it’s a community behavioral health agency versus a Nationwide Children’s behavioral health therapist, we make sure that we are in lockstep with whomever the school is working with on the therapy perspective to make sure that they can refer in, and we will co-manage a patient with either a NCH behavioral health therapist or a community behavioral health therapist. So very similar to Dr. Boye,
Carol Vassar, podcast host/producer:
Dr. Irwin, Nationwide’s data, and I was amazed at this, show that trained primary care clinicians manage most school-identified behavioral health needs with limited psychiatric consultations. What’s the training there? What are the decision supports that are making that possible?
Mary Kay Irwin, EdD, Nationwide Children’s:
So we worked really closely with our psychiatrist to develop a curriculum that is designed for primary care providers that work in schools. The curriculum is relevant for any primary care provider that wants to offer primary care mental health, but it was designed specifically with individuals who are working in a school setting. And we actually worked with the Joe Burrow Foundation to turn these into modules so it can be shared beyond the Nationwide program.
And so there are nine virtual modules that have been created with a ton of resources attached. And so what we do now that we have them electronic is we have all of the Nationwide Children’s school-based providers go through The Burrow Blueprint nine-module series, which creates a baseline of understanding, right, in terms of level of comfort with ADHD, anxiety, and depression, for sure, and a few other things. And then within that, we know it’s also important for primary care providers to learn how to bridge care while a child is waiting for therapy. So we also work with them to teach different techniques and how that provider can bridge care.
And then as the second tier, our psychiatrist that we work most closely with, she offers case consultation. So we get one hour of her time every single week, and all of the primary care providers in school health jump on a call, and cases are presented. And even if you don’t have a case, you jump on because you want to learn from somebody else’s circumstance. And the longer we started doing that, then we realized that what we were actually doing is expanding the scope of the provider to practice independently because they kept learning unique strategies, which is then reducing their need to actually refer that patient out.
And then, of course, for those that are just really needing to be managed by the expert, then we offer the telepsychiatry care. Once this program was completely up and running, we started tracking data to see how it was making a difference. And what we found is once the primary care provider was comfortable, 97% of the referrals that came to a school-based health center for behavioral health were effectively managed within the school-based health center with that oversight of child psychiatrist and did not require a referral out, did not require to be independently managed by the child psychiatrist.
What this effectively did was reduce the psychiatry wait time for our psychiatrists by four months. And so it was extremely… If I’m being honest, it was more successful than we even anticipated. So we’re proud of that, and that’s why we developed these to be shareable resources because it has made such a difference for the children that we aim to serve.
Carol Vassar, podcast host/producer:
You’re going to have to send me a link so I can get those in the show notes, and congratulations on that success. It is wildly successful. That program is just spot on.
I want to talk a little bit about stigma. There is still a stigma around mental health, receiving mental health care. Have you, either of you, encountered resistance to your models, either from parents, from faculty, staff, students, anyone outside because of stigma? And if you have, how do you work to overcome it? Dr. Boye.
Jason E. Boye, PhD, Nemours Children’s Health:
When I think of my direct face-to-face encounters with families, I would say there is less stigma at that point because they are face-to-face with me. I think that what we really try to do within our school-based health centers is, really, to join that school community. So we are out in the halls in the morning when students are coming in, greeting students, floating and mingling with the school staff. We attend and are asked to attend those after-school activities, family engagement nights, back to school nights, parent-teacher conferences. And so really just trying to show that we are part of the school community and to help… It’s not this scary psychologist or behavioral health therapist, but there’s a person here with the name and a face, and that helps to reduce that stigma.
But there’s always going to be some stigma. Maybe not always, but there is still some stigma associated with behavioral health services. And I think it’s really just trying to have those conversations and really learn for that individual what is the concern, because oftentimes, you can work around it and really help to provide education on what’s a psychologist, what a behavioral health therapist does, the services they provide, their scope and work to also better inform and educate about privacy and confidentiality, both within a medical system and more specific to behavioral and mental health.
Carol Vassar, podcast host/producer:
Dr. Irwin, anything to add there?
Mary Kay Irwin, EdD, Nationwide Children’s:
I would agree. We work hard to ingratiate ourselves in the community, as Dr. Boye mentioned, and find success in becoming a part of that community and developing that rapport and that trust. The only other thing I would say is that sometimes if a family is resistant to being referred directly to a behavioral health therapist, they’re still open to seeing their primary care doctor, right, because that’s the pediatrician. And so when our pediatricians that are working in schools and nurse practitioners working in schools are trained to do primary care, mental health, they can start doing some activities to bridge care before we name it, right-
Carol Vassar, podcast host/producer:
Mm-hmm.
Mary Kay Irwin, EdD, Nationwide Children’s:
… and before we say, “You have to have a therapist.” And so they’re empowered with the tools, whether it’s a chart, a behavior chart, or it’s… There’s all kinds of tools that we give them, and so they can start an intervention to address what’s likely to be named a mental health diagnosis before and walk the child in the family along. Some never get there and some do, right?
Carol Vassar, podcast host/producer:
Mm.
Mary Kay Irwin, EdD, Nationwide Children’s:
And then the other thing I would say is it’s not uncommon too that we’ll have someone maybe who has had a diagnosis but doesn’t want to do medication. And so the same thing would occur, right? And so we would be able to do some bridging of care and working with that family through the primary care doctor’s office and walk them along, answering questions, increase comfort to see if we can get them to a point of acceptance. And sometimes it works, and sometimes it does not.
Carol Vassar, podcast host/producer:
In the way that this program works, I would love for each of you to walk us through your financing blend, whether it’s Medicaid, commercial billing, district contracts, philanthropic support, state support, and are there friction points? Are there ways that you’ve unlock sustainability? Dr. Boye.
Jason E. Boye, PhD, Nemours Children’s Health:
Well, the answer is yes. All of those things provided us such a-
Carol Vassar, podcast host/producer:
All of the above.
Jason E. Boye, PhD, Nemours Children’s Health:
… and it rotates. To be honest, we’re always looking for support for the programs and exploring different funding, mechanisms, and opportunities. One of the friction points that we run into in Delaware, there’s two that I’ll highlight that we’re continuing to advocate for, is school-based health centers have been designated in the state since the ’80s and have been primarily in high schools, and they’re required to be in high schools. And therefore, they received some state funding for those school-based health centers. But we don’t have that reciprocity for our middle, or elementary, or early childhood education centers.
Secondly, we run into a barrier with private insurance in particular, because school-based health centers are not recognized as a place of service. And so we can provide the same behavioral health therapy, primary care service, use our same billing codes that we would in a traditional office visit encounter. But because that place of service is a school-based health center, we don’t get that same reimbursement that we would. We’re fortunate that our Medicaid provider does recognize it as a place of service, but continuing to advocate for net reciprocity with our private insurers.
Carol Vassar, podcast host/producer:
I want to turn our attention to policy. Are there policy barriers that either of you have faced and have managed to overcome? Are there still some policy barriers that remain? Dr. Boye.
Jason E. Boye, PhD, Nemours Children’s Health:
So one policy barrier, I think, is what I was alluding to earlier with the reimbursement and funding source from the state for our school-based health centers. Another issue that we had run into that we have overcome is we wanted to work to increase training for mental health clinicians in our school-based health center. And often, these are our psychology interns and residents or externs, which are graduate students. And because they are pre-licensed, even though they’re operating under the supervision of a licensed clinical provider, they were excluded from being able to have clinical rotations in school-based health centers.
And so this past year, we were able to partner with our legislative team to have mental health rotations approved by the State Department of Public Health, and that legislation passed in the summer. And actually, just this morning, my mental health rotations for our Nemours school-based health centers were approved so that we can begin to train additional mental health clinicians in school-based behavioral health to help with that behavioral health provider shortage that Dr. Irwin was speaking to earlier.
Carol Vassar, podcast host/producer:
Well, congratulations on that. As we close out today, and this is the first two parts, for anyone who’s listening or watching. For districts and health systems that want to get a program like this started, maybe they have the school-based health centers already, what is the short playbook for launching a similar program, and also, what’s next for your respective programs? Dr. Irwin.
Mary Kay Irwin, EdD, Nationwide Children’s:
I always tell people that the first recipe for success is to make sure you go where there’s unmet need. Sometimes people try to go to places they want to be in, but there’s already services there. I mean, we just have too much need to be duplicative, so the first recipe for success is to make sure that you’re taking these important, often limited resources to areas that need your help the most.
The other recipe for success is authentic partnership. So there have been times where we have come to a school, and the school, for whatever reason, just didn’t feel like it was a need. And if they can’t embrace it fully, oftentimes, you struggle for success, because as I always mentioned to people, this is not outpatient medicine that happens to be located at a school. This is integrated care within a school, so it has to be authentic on both sides. That goes for the healthcare provider too. Healthcare providers who approach this work like, “Oh, it’s just typical outpatient medicine in a school,” and they’re not willing to do the kinds of things that Dr. Boye mentioned, the ingratiating yourself into the school community, that is a challenge.
And then the other is lean on experts. There’s so many people doing this work and doing it well, and we have already scraped our knees and bumped our elbows. And so when you want to do this work, reaching out to somebody else who’s already done it so you can step over the potholes, so to speak, and not sink your foot in it, we want to help. There’s no competition in this work, and the more we can help each other, the better.
Carol Vassar, podcast host/producer:
Yeah.
Mary Kay Irwin, EdD, Nationwide Children’s:
As far as where we’re headed, we want to continue to expand the program. And then specifically, we’re very interested in leveraging The Burrow Blueprint that we created and those virtual modules, and starting to offer that to other providers in school-based medicine, and see if we can help other people to reach the same success that we have with that program.
Carol Vassar, podcast host/producer:
Dr. Boye.
Jason E. Boye, PhD, Nemours Children’s Health:
I echo so much of what Dr. Irwin just shared. I really think that going into communities where there is unmet needs for behavioral health, there are issues with accessing behavioral health services is the first key to success. And then secondly, really, partnering with those schools to make sure that there is a shared vision, and that we come together for what this looks like, and how we can be integrated on providing this behavioral healthcare and school-based health center services within the school.
Just like Dr. Irwin, we work in a lot of different schools, and you can feel how that integration is different across schools and the ones that are more lockstep. It fills a much bigger need because everyone is working. We’re rowing in the same direction. And so those collaborations and connections are a particular importance.
I would also share that in addition to leaning on those, who has some experience in this work, the National School-Based Health Alliance is a great resource. They have some different playbooks and resources available online, and many states have their own chapter of a school-based health alliance, and that has been particularly helpful. In Delaware, we convene what’s a quarter as a Delaware chapter of the School-Based Health Alliance and just hearing how others are navigating the difficulties of school-based health work at times.
And as far as next steps, continuing to grow and to reach different areas in the state of Delaware. Delaware is a smaller state geographically speaking, but there are many school districts and many schools that do not have school-based health centers and really working to identify where that need is, and then partner with those districts and schools on bringing our school-based health center services to them.
Carol Vassar, podcast host/producer:
And one more resource that I’m going to add to the list, we’re going to put a link to this in the show notes, is the new white paper from Nemours National Office of Policy and Prevention. It’s called Promoting Mental Wellbeing for Children: Promising Pediatric Mental Health Models That Help Children Thrive. That is the underpinning of this podcast episode, and the next one that we’re going to do all on this topic.
So, Dr. Irwin from Nationwide Children’s, Mary Kay Irwin that is, and Dr. Jason Boye from Nemours Children’s Health, thank you so much for giving us a preview of that. Next time around, we’re going to talk about telehealth, and we’re going to talk about relational health and how that can be brought to bear in the same sphere. So thank you all for joining us. I’m Carol Vassar. And remember, we can change children’s health for good well beyond medicine.
MUSIC:
Let’s go, oh, oh. Well Beyond Medicine.
