School Community Partnership for Mental HealthStory Session

Sheri Johnson, Medical College of WisconsinPaul Florsheim, University of Wisconsin, MilwaukeeSebastian Ssempijja, Sebastian Family Psychology PracticeCharlie Bauernfeind, Milwaukee Public SchoolsCarrie Koss Vallejo, IMPACT Planning Council

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.”

Getting to know our audienceWhat field do you work in?

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1. Healthcare

2. Behavioral Health

3. Education- At a university

4. Education- K-12

5. Community Based Org

6. Community Activist

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.

PartnersSchools in

Wisconsin’s largest district

Community Mental Health Providers

HMOs

Sebastian Family Psychology

Practice, LLC

CHWs/Research Assistants

Academic Partners Funders

Story Session OutlineChapter 1: SCPMH – The Early Years

Needs AssessmentBuilding the model Addressing systems barriers

Chapter 2: SCPMH- The Middle YearsPerspectives from School Staff, Community Mental Health Providers, Researchers & Community Health Workers

Case Discussion

Story Session Outline

Chapter 3: SCPMH- GraduationTreatment InitiationSchool and Parent SatisfactionBehavioral ImprovementStigma

Chapter 4: SCPMH-Lessons Learned

Chapter 1 –The Early YearsNeeds Assessment, Model Building, Barrier Busting

Photo from City of Milwaukee’s I want a strong baby public health campaign

The Early Years (2005-2009)1) National Family Week Partnership

study (2005) of mental health services for youth in Milwaukee –

ACCESS IS PROBLEMATIC.

2) Milwaukee Public Schools estimated only-

5% of STUDENTS GET CARE.

3) 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

The Early Years (2008-2009)

The Middle Years:Pilot strategies

Views from School Staff, Community Mental Health Providers, Researchers and Community Health Workers

Case Discussion

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

II

I

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• Refer selected students• Obtain ROI• Consultation with Guardian• Individual / Family Therapy

• Consultation with Staff• Classroom

presentations

• School embedding activities

SBIRT & PBIS3 Levels of Support System

SCPMH Community CoordinatorThe 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

SCPMH School CoordinatorThe 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 

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 processSchool calendar and attendance are issues

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

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

What is the first priority for a CHW when meeting a family?

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1. Get a Release of Information (ROI)

2. Sign family up for research

3. Connect family to support services

4. Build an alliance/trusting relationship

Community Mental Health Agency Perspective

Reflections on the processAdministrator buy inClinicians who had the “right fit”Provider/Client Alliance

Community Mental Health Agency Perspective

Implementation experiences and deliverablesCulture shiftAgency utilizationFeedback and ongoing assessmentStandardization of and operational momentum

Researcher PerspectiveAssessing readiness for research vs. evaluation

Balancing rigor and feasibilityData 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

Case Study DiscussionPhoto credit: MCW Annual Report – SCPMH staff from Medical College of

Wisconsin, Milwaukee Publics Schools, IMPACT Planning Council and Sebastian Family Psychology Practice.

How should SCPMH intervene?12 year old male studentClassmates report he was bit by a dog

Teacher notes grades starting to slipSSW engages student, provides social emotional support

Student develops attendance issuesSSW discovers student and mother were victims of random gunfire

Student detaches from friends

What are the major obstacles to school based mental health services?

1. Teachers are resistant2. School administrators

won’t allow it3. Community providers

aren’t interested4. Parents are not

invested5. There is no good

source of funding

Evidence Based Therapy is overrated and hard to implement in real world settings

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How important is it that families who receive therapy participate in the research?

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Chapter 3: GraduationDo we have the data to go forward?

Stages of Implementation (Perales, Johnson, Barret and Eber)

Focus Stage Description

Exploration/Adoption

Decision regarding commitment to adopting the program/practices and supporting successful implementation.

Installation Set up infrastructure so that successful implementation can take place and be supported. Establish team and data systems, conduct audit, develop plan.

Initial Implementation

Try out the practices, work out details, learn and improve before expanding to other contexts.

Elaboration Expand the program/practices to other locations, individuals, times- adjust from learning in initial implementation.

Continuous Improvement/Regeneration

Make it easier, more efficient. Embed within current practices.

What did we learn?Treatment Initiation RatesStigmaProgram Satisfaction and ChallengesSchool Staff ParentsMental Health Providers and Community Health Workers

Behavioral Improvement

Treatment Initiation

Perceptions of Stigma among School Staff and Parents

Program EvaluationOpen 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)

Overarching Themes - Positive Access

Safe environment for kidsConvenient for parentsSmart/Efficient for everyone

PartnershipNovelHelpfulNeeded

OutcomesBehavior change

Overarching Themes - NegativeLogistics

ConsentCommunicationCapacityCoordination

Parent InvolvementLower than desired

Missed opportunity for input

Missed opportunity for addressing stigma

Stigma

+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.”

+In their own wordsParent: “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.”

Behavioral and Academic Outcomes – The PlanAdministrative School Data for all students referred to SCPMHAttendance office referraldisciplinary action special education status standardized test scores

Behavioral and Academic Outcomes-The Plan

For those who consented to research: Strengths and Difficulties Questionnaire baseline, 3 months, 6 monthsparent, teacher, student

Revised Working Alliance Inventory 4 weeks, 6 monthsparent, teacher, student

Behavioral Outcomes 2011-2012 cohort

1) Office Referrals:

Significant difference betweenpre/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.

Office Referrals- trend toward decline for those in therapy

Attendance – going the wrong direction?

Chapter 4: Lessons LearnedFrom the real world

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.

Is SCPMH Community Engaged Research

45*Modified version from International Association for Public Participation Principles of Community Engagement , 2nd Edition CTSA Consortium

Lesson Learned:

How do we engage parents as co-collaborators in program development, implementation and evaluation?

CHW/Parent Interactions

School Staff Survey Results

*Dichotomized for Satisfied/Not Satisfied

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

49Source: Watson, and Foster-Fishman (2013) The Exchange Boundary Framework: Understanding the Evolution of Power within Collaborative Decision-Making Settings. Am J Community Psych

Stakeholders have opportunity and capacity to:•Activate and incorporate resources into exchanges•Value less-advantaged stakeholder resources

Increased

Resource Exchang

e

Less-advantaged stakeholders better able to

leverage dependencies

through resource exchanges 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

Expanded Social Boundari

es

Increased range of resources

that less-advantaged stakeholders

can legitimately exchange

Critical Processes within the Exchange Boundary Framework

Watson and Foster-Fishman (2013)

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Acknowledgements Dena Radtke and staff, MPS

Sue McKenzie, Rogers Memorial Hospital

Katie Pritchard and staff, IMPACT Planning Council

Audrey Potter, IMPACT Planning Council

Pippa Simpson and staff, MCW

Chelsea Hamilton, MCW

Sandy Bogar, MCW; Vania Trejo, Zoey Schmidt, UWM

Kevin O’Brien and staff, Aurora Family Services

Cathy Arney and staff, Pathfinders Milwaukee

Sebastian Family Practice staff

Families and staff at OW Holmes, Hopkins Lloyd, Wedgewood Park and Audubon.