S chool C ommunity P artnership for M ental H ealth

1. Sheri Johnson, Medical College of Wisconsin Paul Florsheim, University of Wisconsin, Milwaukee Sebastian Ssempijja, Sebastian Family Psychology Practice Charlie Bauernfeind, Milwaukee Public Schools Carrie Koss Vallejo, IMPACT Planning Council School Community Partnership for Mental Health Story Session

2. Using the Clickers • Each of you has a “clicker” that will allow you to respond to questions during the presentation, and we’ll be able to see the responses. • Please use the pad of your finger to press buttons –not your fingernail. • You can change your answer, but only your last response will “count.”

3. Getting to know our audienceWhat field do you work in? • Healthcare • Behavioral Health • Education- At a university • Education- K-12 • Community Based Org • Community Activist

4. SCPMH Goal Statement • The goal of the School Community Partnership for Mental Health is to: • refine and demonstrate the effectiveness of • a collaborative partnership model of mental health promotion and service • to influence systems changes needed for sustainability.

5. Partners Sebastian Family Psychology Practice, LLC

6. Story Session Outline • Chapter 1: SCPMH – The Early Years • Needs Assessment • Building the model • Addressing systems barriers • Chapter 2: SCPMH- The Middle Years • Perspectives from School Staff, Community Mental Health Providers, Researchers & Community Health Workers • Case Discussion

7. Story Session Outline • Chapter 3: SCPMH- Graduation • Treatment Initiation • School and Parent Satisfaction • Behavioral Improvement • Stigma • Chapter 4: SCPMH-Lessons Learned

8. Chapter 1 –The Early Years Needs Assessment, Model Building, Barrier Busting Photo from City of Milwaukee’s I want a strong baby public health campaign

9. The Early Years (2005-2009) • National Family Week Partnership study (2005) of mental health services for youth in Milwaukee – ACCESS IS PROBLEMATIC. • Milwaukee Public Schools estimated only- 5% of STUDENTS GET CARE. • Youth Mental Health Connections, COMMITS TO ACTION. Connecting Need and Capacity: A Study of Mental Health Services for Youth in Milwaukee County Lengyel et al 2005

10. The Early Years (2008-2009)

12. The Middle Years: Pilot strategies Views from School Staff, Community Mental Health Providers, Researchers and Community Health Workers Case Discussion

13. The Middle Years: 2009-2013 • Three community-based agencies providing consultation and direct services in collaboration with four Milwaukee Public Schools • Project coordinator working with Leadership Team to oversee implementation • Public Health researchers developing and testing a process for outcomes research incorporating Community Health Workers • Operations manual and referral system being developed to support expansion

14. SBIRT & PBIS 3 Levels of Support System • Refer selected students • Obtain ROI • Consultation with Guardian • Individual / Family Therapy • Consultation with Staff • Classroom presentations • School embedding activities III II I

15. SCPMH Community Coordinator • The coordinator is the “go-to” person for the participating community mental health agencies • The coordinator assures that the community partners understand and comply with their roles • The coordinator works with insurance providers, community health workers, government agencies, and university researchers to enhance collaborative efforts

16. SCPMH School Coordinator • The coordinator is the “go-to” person for schools • Coordinates school events and communications • Assures record keeping and data collection • Addresses problems at schools • Assures compliance with SCPMH policies and procedures 

17. School Staff Perspective • Mental Health is taboo → Mental Fitness • Overcoming “union” issues • Need full-time support services staff to triage • Building Bridges to schools takes time • The Building Principal • The Pupil Services Support Staff •  The Classroom Teacher • Building trust is a slow process • School calendar and attendance are issues

18. COMMUNITY HEALTH WORKER ROLE-Bridge Building • Assist with delivery and completion of initial paperwork by parents- ROIs, research consents and data • Conduct “check-ins” with providers and teachers • Assure two-way communication with families • Provide links to broad range of resources – school social worker and others • Participate in school’s family events and staff meetings • Provide a cultural bridge for families to schools and providers

19. Community Health Worker (CHW) Perspective • New role • Research assistant • Varied responsibilities: • Making home visits • Sharing info with therapist and school • Finding additional services for clients

20. What is the first priority for a CHW when meeting a family? • Get a Release of Information (ROI) • Sign family up for research • Connect family to support services • Build an alliance/trusting relationship

21. Community Mental Health Agency Perspective • Reflections on the process • Administrator buy in • Clinicians who had the “right fit” • Provider/Client Alliance

22. Community Mental Health Agency Perspective • Implementation experiences and deliverables • Culture shift • Agency utilization • Feedback and ongoing assessment • Standardization of and operational momentum

23. Researcher Perspective • Assessing readiness for research vs. evaluation • Balancing rigor and feasibility • Data collection challenges • Consenting • Gathering data over time from multiple sources • Using administrative data sources to measure outcomes • Using real time data to inform implementation and sustainability

24. Case Study Discussion Photo credit: MCW Annual Report – SCPMH staff from Medical College of Wisconsin, Milwaukee Publics Schools, IMPACT Planning Council and Sebastian Family Psychology Practice.

25. How should SCPMH intervene? • 12 year old male student • Classmates report he was bit by a dog • Teacher notes grades starting to slip • SSW engages student, provides social emotional support • Student develops attendance issues • SSW discovers student and mother were victims of random gunfire • Student detaches from friends

26. What are the major obstacles to school based mental health services? • Teachers are resistant • School administrators won’t allow it • Community providers aren’t interested • Parents are not invested • There is no good source of funding

27. Evidence Based Therapy is overrated and hard to implement in real world settings • True • False

28. How important is it that families who receive therapy participate in the research? Please rate 1 (lowest) - 5 (highest) • 4 • 4 • 4 • 4 • 5 1 2 3 4 5

29. Chapter 3: Graduation Do we have the data to go forward?

30. Stages of Implementation (Perales, Johnson, Barret and Eber) Should we do it Getting it right Making it better

31. What did we learn? • Treatment Initiation Rates • Stigma • Program Satisfaction and Challenges • School Staff • Parents • Mental Health Providers and Community Health Workers • Behavioral Improvement

32. Treatment Initiation

33. Perceptions of Stigma among School Staff and Parents

34. Program Evaluation • Open ended interviews with parents of students enrolled in treatment(N=6) • Open ended interviews with principals from 4 schools (N=4; 100% response) • Closed ended survey data from staff at 4 schools (N=171; 69% response rate) • Open ended survey data from community mental health providers and community health workers (N=9; 100% response rate)

35. Overarching Themes - Positive • Access • Safe environment for kids • Convenient for parents • Smart/Efficient for everyone • Partnership • Novel • Helpful • Needed • Outcomes • Behavior change

36. Overarching Themes - Negative • Logistics • Consent • Communication • Capacity • Coordination • Parent Involvement • Lower than desired • Missed opportunity for input • Missed opportunity for addressing stigma • Stigma

37. In their own words: • Principal: “If it went away, we wouldn’t have institutional knowledge of where to place students, but then again there’s that therapeutic piece where you have that connection between somebody that’s coming in here on a consistent basis, building relationships with students and providing strategies and solutions. I’ve seen firsthand where that’s really effective.” • CHW: “More communication between the therapist and CHW, on a regular basis, is a must in order to make sure that everyone is on the same page as far as clients and their treatment.”

38. In their own words • Parent: “I believe a lot of parents would feel like they’re all by themselves and they don’t have any help, cause that’s how I felt for a long time, like ‘I’m the only one going through this,’ until you find out there’s other parents going through what you’re going through.” • Provider: “After the school year was over clients did not want to come to the office, some parents did not have time, others did not feel comfortable driving to the office. So out of 10 cases, just one family followed up with therapy during the summer.”

39. Behavioral and Academic Outcomes – The Plan • Administrative School Data for all students referred to SCPMH • Attendance • office referral • disciplinary action • special education status • standardized test scores

40. Behavioral and Academic Outcomes-The Plan • For those who consented to research: • Strengths and Difficulties Questionnaire • baseline, 3 months, 6 months • parent, teacher, student • Revised Working Alliance Inventory • 4 weeks, 6 months • parent, teacher, student

41. Behavioral Outcomes 2011-2012 cohort 1) Office Referrals: Significant difference between pre/post intervention (p<.03) 2) Disciplinary Action Taken: Significant difference between pre/post (p<.0065) Wilcoxon signed rank sum test used to test the significance of two paired samples.

42. Office Referrals- trend toward decline for those in therapy

43. Attendance – going the wrong direction?

44. Chapter 4: Lessons Learned From the real world

45. Is SCPMH Community Engaged Research Increasing Level of Community Involvement, Impact, Trust, and Communication Flow Outreach Consult Involve Collaborate Shared Leadership Some Community Involvement Communication flows from one to the other, to inform Provides community with information. Entities coexist. Outcomes: Optimally, establishes communication channels and channels for outreach. More Community Involvement Communication flows to the community and then back, answer seeking Gets information or feedback from the community. Entities share information. Outcomes: Develops connections. Better Community Involvement Communication flows both ways, participatory form of communication. Involves more participant with community on issues. Entities cooperate with each other. Outcomes: visibility of partnership established with increased cooperation. Community Involvement Communication flow is bidirectional Forms partnership with community on each aspect of project from development to solution. Entities form bidirectional communication channels. Outcomes: Partnership building, trust building. Strong Bidirectional Relationship Final decision making at community level. Entities have formed strong partnership structures. Outcomes: Broader health outcome affecting broader community. Strong bidirectional trust built. *Modified version from International Association for Public Participation Principles of Community Engagement , 2nd Edition CTSA Consortium

46. Lesson Learned: • How do we engage parents as co-collaborators in program development, implementation and evaluation?

47. CHW/Parent Interactions

48. School Staff Survey Results *Dichotomized for Satisfied/Not Satisfied

49. The Exchange Boundary Framework: Understanding the Evolution of Power within Collaborative Decision-Making Settings -Watson and Foster-Fishman (2013) • The presence of disadvantaged stakeholders at decision-making tables does not ensure the: • valuing • access • use • of their resources Source: Watson, and Foster-Fishman (2013) The Exchange Boundary Framework: Understanding the Evolution of Power within Collaborative Decision-Making Settings. Am J Community Psych

50. Critical Processes within the Exchange Boundary Framework Less-advantaged stakeholders better able to leverage dependencies through resource exchanges • Stakeholders have opportunity and capacity to: • Activate and incorporate resources into exchanges • Value less-advantaged stakeholder resources Increased Resource Exchange Increased power for less-advantaged stakeholders to authentically influence decisions • Stakeholders have opportunity and capacity to engage in discourse to: • Increase critical consciousness of boundaries around legitimate exchanges • Value expanded boundaries Increased range of resources that less-advantaged stakeholders can legitimately exchange Expanded Social Boundaries Watson and Foster-Fishman (2013)