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A discussion of the NH Center for Public Policy's study of mental health services in New Hampshire's schools.
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1
All of our reportsare available on the web:
www.nhpolicy.org
New Hampshire Center New Hampshire Center for Public Policy Studiesfor Public Policy Studies
“…to raise new ideas and improve policy debates through quality information and analysis on issues shaping New Hampshire’s future.”
Board of DirectorsDonna Sytek, Chair
John B. Andrews
John D. Crosier, Sr.
William H. Dunlap
Sheila T. Francoeur
Chuck Morse
Todd I. Selig
Stuart V. Smith, Jr.
James E. Tibbetts
Brian F. Walsh
Kimon S. Zachos
Martin L. Gross, Chair Emeritus
StaffSteve Norton, Executive Director
Ryan Tappin
Cathy Arredondo
2
Mental Health in New Hampshire’s Schools
CMH Community of Practice and NHASEA
June 12, 2009
Ryan Tappin, Research Associate
3
Why look at mental health and schools?
4
Top 20 providers of MH services for children
Total Expenditures for Mental Health Services for Medicaid Enrolled Children Up to age 19 for the Top 20 Providers
Provider Total Expenditures Service Count
RIVERBEND COMMUNITYMENTAL HEALTH $3,840,202 22,205
THE MENTAL HEALTH CENTER OF GREATER MANCHESTER $3,426,685 18,817
LAKES REGION MENTAL HEALTH $3,013,125 15,118
WEST CENTRAL BEHAVIORAL HEALTH $2,674,982 18,875
MONADNOCK FAMILY SERVICES $2,602,120 15,333
SEACOAST MENTAL HEALTH CENTER $2,487,523 12,907
MOUNT PROSPECT ACADEMY INC $2,444,888 1,632
COMMUNITY COUNCIL OF NASHUA $2,201,147 14,849
ODYSSEY HOUSE INC $1,683,859 647
BEHAVIORAL HEALTH SERVICES $1,586,829 9,558
NASHUA CHILDREN'S HOME $1,527,389 1,103
CLM BEHAVIORAL HEALTH SYSTEMS $1,506,753 9,288
EASTER SEALS NH $1,487,099 887
EASTER SEALS NH INC - ZACHARY RD $1,393,243 550
NEW HAMPSHIRE HOSPITAL $1,354,952 251
LUTHERAN COMMUNITY SERVICES OF NORTHERN NEW ENGLAND $1,030,063 838
ECKERD FAMILY YOUTH ALTERNATIVE $960,273 385
MANCHESTER SCHOOL DISTRICT $904,534 18,897
EASTER SEAL SOCIETY OF NH INC $895,072 436
NASHUA SCHOOL DISTRICT $852,734 22,967
Interesting!
5
Schools provided $13.5 million in
Medicaid funded MH services in 2005
Total Expenditures for Mental Health Services for Medicaid Enrolled Children Up to age 19 by Provider Type
Provider TypeTotal
ExpendituresService Count
Total Children
Average Costper Child
Average Cost
per Service
Average Number of Services per
Child
Mental Health Clinic $25,191,173 148,927 6,544 $3,850 $169 23
Private Non-Medical Institution $21,548,382 13,270 1,251 $17,225 $1,624 11
School Health Services $13,525,760 253,390 4,680 $2,890 $53 54
Home and Community Based Care $4,951,315 20,587 638 $7,761 $241 32
Day Rehabilitation Center $4,382,659 19,460 1,402 $3,126 $225 14
DCYF Services $4,061,514 4,139 207 $19,621 $981 20
Psychologist $2,538,164 36,305 3,559 $713 $70 10
6
Which schools are providing the most services?
Total Expenditures for Mental Health Services for Medicaid Enrolled Children Up to age 19 for the Top 20 School Districts
School DistrictTotal
Expenditures
Percent of All School Service
Expenditures
Service Count
Percent of AllServices
Provided
MANCHESTER SCHOOL DISTRICT $904,534 7% 18,897 7%
NASHUA SCHOOL DISTRICT $852,734 6% 22,967 9%
MERRIMACK SCHOOL DISTRICT $661,437 5% 9,922 4%
CONVAL SCHOOL DISTRICT $377,535 3% 4,391 2%
MONADNOCK REGIONAL SCHOOL $352,681 3% 6,316 2%
TIMBERLANE REGIONAL SCHOOL DISTRICT $319,151 2% 6,097 2%
JAFFREY/RINDGE SCHOOLS $311,111 2% 95 0%
HAVERHILL COOPERATIVE $299,162 2% 2,651 1%
FALL MOUNTAIN REGIONAL SCHOOL $290,006 2% 5,373 2%
ROCHESTER SCHOOL DISTRICT $286,190 2% 3,234 1%
CONCORD SCHOOL DISTRICT $258,594 2% 1,278 1%
DERRY COOPERATIVE $255,921 2% 339 0%
THE EXETER REGION COOPERATIVE $245,518 2% 2,870 1%
LACONIA SCHOOL DISTRICT $236,603 2% 4,312 2%
PORTSMOUTH SCHOOL DISTRICT $234,351 2% 4,957 2%
CLAREMONT SCHOOL DISTRICT $229,291 2% 4,337 2%
DOVER SCHOOL DISTRICT $224,376 2% 7,266 3%
LONDONDERRY SCHOOL DISTRICT $200,426 1% 8,006 3%
SALEM SCHOOL DISTRICT $184,833 1% 4,066 2%
CONWAY SCHOOL DISTRICT $181,819 1% 2,973 1%
7
What services are schools providing?
Total Expenditures for Mental Health Services for Medicaid Enrolled Children up to 19by CPT Code
CPT Code DescriptionTotal
ExpendituresService Count
90810
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approx. 20 to 30 min. face-to-face with the patient $202,476 5,975
H0046 Mental health services, not otherwise specified $558,003 25,275
H2017 Psychosocial rehabilitation services, per 15 min. $12,765,281 222,140
Total $13,525,759 243,664
8
What we wanted to find out
• More specifically, what services are schools providing?
• How are schools supporting these services and how is funding administered?
• Who are the practitioners providing those services?
• What mental health issues are most commonly seen in the school setting?
• What barriers exist to providing school-based mental health services?
9
What we did – Part 1
• Fielded 2 surveys taken from a national survey of school-based mental health, conducted nationally by SAMHSA in 2002
• Sent survey to all districts and all schools to eliminate sampling bias
• Response rate – 19% of schools and 31% of districts
10
What we did - Part 2
• Interviews with Children’s Directors at the Community Mental Health Centers.
• Discussions focused around:– The arrangements of formal agreements with schools
districts.– The existence and structure of informal agreements
for services and other informal relationships between CMHCs and schools.
– Advantages, disadvantages, successes, and barriers in providing mental health services in schools.
11
Survey Results
12
Administration and Funding
13
Who receives services?
Students Receiving Mental Health Services
All Students, 86%
Special Ed Students Only,
9%
Not Available, 5%
14
Who has the administrative responsibility?
Administrative Responsibilty for Mental Health Services
School 28%
Administrative Responsibility at
the School District72%
15
What is the relationship between MH and SPED?
Administration of Special Education and Mental Health Services
Together68%
Separately32%
16
How are MH services budgeted?
Mental Health Services Budgeted Separately from Other Education Expenditures
Mental Health Budgeted Separately
48%
Not Separately Budgeted
52%
17
Funding for School Mental Health
Percent of School Districts Indicating Each as a Source of Funds for Mental Health Services
84%
80%
76%
64%
64%
28%
16%
16%
12%
12%
8%
4%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
Local Funds
Medicaid
IDEA
Title IV
State Special Ed
Third Party
Community Health Services BlockGrant
General Fund
Title 1
Safe Schools Initiative
Self-Pay
Private Foundation
18
Has funding for MH changed over the past year?
Changes in Funding Level for Mental Health Services for Students
Decreased24%
Remained the same48%
Increased24%
Not Available4%
19
Mental Health Issues in Schools
20
What MH issues are school services treating?
Percentage of NH Schools that Ranked the Following Mental Health Problems as Among their Top Three Problems for Male and Female Students, 2007-2008
69%
61%
43%
22%
29%
17%
80%
19%16%
28%
54%
27%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
SocialInterpersonal
Or Family
AggressiveDisruptiveBehavior
Behaviorproblems assoc
with neuro
AdjustmentIssues
Anxiety stressschool phobia
Depression
MalesFemales
21
22
What MH issues are school services treating?
Percentage of NH Schools that Ranked the Following Mental Health Problems as Among their Top Three Problems for Male and Female Students, 2007-2008
69%
61%
43%
22%
29%
17%
80%
19%16%
28%
54%
27%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
SocialInterpersonal
Or Family
AggressiveDisruptiveBehavior
Behaviorproblems assoc
with neuro
AdjustmentIssues
Anxiety stressschool phobia
Depression
MalesFemales
23
Social, interpersonal, and family issues are most common
Problems Which Use Most of NH School's Mental Health Resources
Aggressive/disruptive behavior, bullying
15%
Behavior problems assoc w neurological disorders
13%
Anxiety, stress, school phobia
8%
Adjustment issues1%
Alcohol/drug problems1%
Major psychiatric or developmental disorders
4%
NA7%
Depression, grief reactions2%
Suicidal or homicidal thoughts or behavior
1%
Social, interpersonal or family problems
48%
24
High schools tend to have different needs
Mental Health or Psychosocial Problems Using Most of the Resources
0%
10%
20%
30%
40%
50%
60%
Social, interpersonalor family problems
Aggressive/disruptivebehavior, bullying
Behavior problemsassoc w neurological
disorders
Anxiety, stress,school phobia
Other
High SchoolMiddle SchoolElementary
25
Mental Health Services Provided
26
What services are school MH programs providing?
Percentage of Schools Providing Various Mental Health Services, 2007-2008
83% 84%
76%80%
75%73%
70%
39%
32%
41%
50%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Assessment BehaviorManagementConsultation
CaseManagement
Referral toSpecializedPrograms
CrisisIntervention
IndividualCounseling
GroupCounseling
SubstanceAbuse
Medication forEmotional orBehavioral
Referral forMedication
Management
FamilySupport
27
NH is not unlike the rest of the nation
28
Few schools are providing screening….
Percent of Schools with School-wide Screening for Behavioral or Emotional Problems
36%
42%
51%
39%
33%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Kindergarten Screening forSocial-Emotional Problems
Health Class Inventory My Voice StudentAspiration Survey
Systemic Screening forBehavioral Disorders
Youth Risk Behavior
29
…and prevention services
Percent of Schools Offering Prevention and Early Intervention Programs and Services
25%
50%
41%
37% 38%
42%
46%
0%
10%
20%
30%
40%
50%
60%
PBIS Responsive Classroom Safe Schools/HealthStudents
Alcohol/Tobacco/DrugUse Prevention
Prevention and Pre-Referral
Outreach to Parents PeerCounseling/Mediation
30
Many barriers to providing services in schools exist…
Percentage of Schools Reporting Extent to Which Various Factors are Barriers to Providing Mental Health Services, 2007-2008
0%
10%
20%
30%
40%
50%
60%
70%
FinancialConstraints of
Families
TransportationDifficulties
CommunityMental Health
ResourcesInadequate
InadequateResources
(e.g. waitinglists)
CompetingPriorities
GainingParental
Cooperationand Consent
Stigma InadequateCoordination
betweenschool andcommunity
Language andCulturalBarriers
ProtectingStudent
Confidentiality
NH
SAMSHA
31
…creating difficulty in providing services
Percent of Schools Indicating Service is Difficult to Provide
21%
13% 13%
32%
21%20%
26% 27%
45%
37% 37%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Assessment BehaviorManagementConsultation
CaseManagement
Referral toSpecializedPrograms
CrisisIntervention
IndividualCounseling
GroupCounseling
SubstanceAbuse
Medication forEmotional orBehavioral
Referral forMedication
Management
Family Support
32
Schools with higher poverty levels find more difficulty in providing
servicesPercent of Schools Indicating Difficulty in
Providing Services by Enrollment in Free and Reduced Lunch Programs
0%
10%
20%
30%
40%
50%
60%
Assessment BehaviorManagementConsultation
Case Management Referral toSpecializedPrograms
Crisis Intervention IndividualCounseling
Group Counseling Substance Abuse Medication forEmotional orBehavioral
Referral forMedication
Management
Family Support
Above State Average with FreeLunchBelow State Average Percentwith Free Lunch
33
Staffing Mental Health Services
34
The majority of MH services are provided by internal staff
Percentage of Schools with Various Types of Staff Who Provide Mental Health Services
(NH=2007-2008, SAMSHA US=2002-2003)
75%
67%
25%21% 21%
17%
6%
77%
69%
12%
44%
16%
9%
2%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
StaffCounselors
SchoolPsychologists
SubstanceAbuse
Counselors
School SocialWorkers
Mental HealthCounselors
Clinical/PHDCounselors
Psychiatrists
NHSAMHSA
35
Little coordination between MH providers and other school staff exists
Percentage of Schools Meeting Weekly To Coordinate Mental Health Activities and Services Within Schools, (US 2002-2003, NH 2007-2008)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
InterdisciplinaryMeetings among
Mental Health(MH) Staff
MH Staff/Teacher Planning
MH Staff/ SpecialEducationplanning
Share MHResources
InformalCommunication
NHUS
36
About half of schools contract with an outside provider
Percent of Schools with a Formal or Contractual Agreement with a Community-Based Organization, 2007-2008
56%
39%
50%47%
0%
10%
20%
30%
40%
50%
60%
High School Middle School Elementary All Schools
37
Individual providers were most reported community partner
Most Frequent Community Partners for Those Schools with Formal or Contractual Relationships with Community-Based Organizations
74%
62%
40%37%
33%
24% 24% 23%
15%
8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
IndividualProviders
County orCommunity
Mental HealthAgency
Juvenile JusticeSystem
Local Hospital CommunityHealth Center
Child WelfareAgency
CommunityService
Organization
Faith BasedOrganization
School BasedHealth Center
Other
38
Collecting Mental Health Services Data
39
One-third of schools do not collect data on MH services provided
Collection of Data on Mental Health Services Provided to Students
Collect or Have Access to
Mental Health Services for Special Ed only, 20%
No Data Collected, 34%
Collect or Have Access to MH
Services Provided (All Students)?,
46%
40
Few schools collect data on specific service elements
Share of Schools that Collect Data on ....
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Data Collected onTypes of MH
Problems
Types of SchoolBased Services
Provided
DemographicCharacteristics of
Service Users
Number of Units ofMental Health
Services
Referrals toCommunity Mental
Health
Referrals forStudents onMedication?
Reporting toDistrict or State
Offices?
41
Schools and the CMHCs
42
Schools and the community mental health centers
• Coordination of services between agencies receiving public support is minimal. This is despite the system relying heavily on public financing.
• This reliance on public financing offers a natural partnership between schools and the CMHCs. However, only about 13% of schools have a formal partnership.
43
Although few formal agreements exist, informal relationships are commonplace
• The types of school-based services (and the agreements that govern them) vary greater across the state.– Logistical agreements– Specific services, like IEP related activities and
psycho educational groups– Very rarely do schools pay directly for individual
services with a CMHC
• Schools are often a catalyst for initiating mental health services. Even through informal relationships with community providers.
44
Barriers create significant challenges to school/CMHC partnerships
• Many challenges to school-based mental health care exist– Expectations between the systems can create a challenge– Parental engagement can be frustrating to schools and providers– Resources, staff and logistical resources are ongoing challenges
• Coverage and geography are significant barriers– Medicaid – parents are often not covered– Private – does not pay for support services and limits treatment
sessions– Self-pay is rare
45
Factors influence success -programs have potential
• Several factors influence whether schools have mental health services available– Buy-in from administration and school boards– Availability of private providers (including CMHCs)– Resources– Stigma
• Open communication is the greatest avenue to success
• Even with challenges, school-based mental health services has the potential to increase access and improve treatment
46
Take Aways
• Schools play a large role in providing MH services to children.
• Little information is available to manage the system in place.
• Little formal coordination of services across systems, particularly among the publicly-supported.
• Significant funding is being utilized without coordination of the various funding sources
47
Thank You
Questions?Thoughts?
Comments?