Integrated Behavioral Health: Connecting Community and School Services

1. Integrated Behavioral Health:Connecting Community and School Services Lauren Arnold LCSW James Wagley LCSW-BACS Vanguard Behavioral Health Consultants LLC

2. Presenters - Lauren • Lauren Arnold, LCSW, received a Bachelor of Science in Psychology from Northeast Louisiana University and a Masters of Social Work from the University of Texas at Arlington • She has practiced social work for the past fifteen years in many different environments, including outpatient clinics, school-based clinics, rural health clinics, Head Start centers, juvenile probation, home health services, and day treatment programs • Lauren is skilled in working with many different populations including young children, school-age children, adolescents, adults, and elderly clients. • Has extensive experience with depression, anxiety, PTSD, at risk youth, children in foster care, families experiencing divorce, oppositional and defiant behavior, school issues, and resolving difficult family and interpersonal issues. • Received specialized training in Trauma Focused Cognitive Behavior Therapy and utilizes this to help clients resolve experiences of trauma including child abuse, sexual abuse, and sexual assault • Provides training in positive behavioral supports for Head Start centers. • She is skilled in individual therapy, family therapy, group therapy, play therapy, in-home counseling and delivering integrated behavioral health services.

3. Presenters - James • James has practiced social work for the past 40 years in Louisiana, Georgia and Arkansas. He has worked in day treatment, residential treatment, psychiatric hospitals, and for the past 12 years in school systems. • His practice emphasis has been in development and implementation of programs and services for children, youth and families. As Supervisor of Student Services for Sabine Parish Schools, James implemented alternative education programs, Positive Behavior Supports, School-based Behavioral Health Services and Coordinated School Health Programs. • Supervised Pupil Appraisal, Health Services, Behavioral Health Services and Neighborhood Place personnel. • Trainer in Adventure Based Counseling, Positive Behavior Interventions and Supports, Brief Solution-Focused Therapy and Motivational Interviewing/Stages of Change, IBH • Founded Vanguard Behavioral Health Consultants LLC in 2010. • Directed the startup of Region 8 Coordinated System of Care Wraparound Agency, Choices. • Provides direct behavioral health services through Vanguard BHC LLC and consultation for the Louisiana Primary Care Association in integrating behavioral health services in primary care settings. He continues to train and consult for school systems and human service organizations throughout Louisiana. • His social work training in systems theory and evidence-based interventions has served him well as a framework to utilize in coordinating services, programs and resources for children, youth and families. For more information go to VanguardBHC.com

4. The Louisiana Story Adolescent School Health Initiative of 1991 • Established under Gov. Buddy Rhomer • Authorized OPH to facilitate and encourage the development of comprehensive school-based health centers in public schools • 64 OPH funded sites (55 full time, 9 part time) • 7 Operated by FQHCs • 7 Operated by school systems • 28 Operated by Health Care Systems (DHH-OPH website data for 2012-13)

5. Act 1225 Juvenile Justice Act of 2003 • Authorized the BESE Board and Juvenile Justice Planning Board to develop a model master plan to: • Improve behavior and discipline in schools • Enhance classroom management • Coordinate SPED and JJ Services • Develop methods for handling school suspensions • Revise zero tolerance policies

6. Act 1225 Continued • Provide mental health services • Provide better assistance to parents • Provide more useful annual reports on behavioral and disciplinary problems for data driven decision making So how many initiatives made it? • As a result of Juvenile justice reform, 2000 incarcerated youth has dropped to around 500

7. ACT 555: Children and Youth Planning Boards Act of 2004 • Passed to further promote the intent of the Juvenile Justice Reform Act of 2003 • Purpose was to assist in the assessment, alignment, coordination, prioritization and measurement of all available C&Y services and programs that address the needs of those at risk for or identified with social, emotional, and developmental problems including but not limited to: • educational failure, abuse, neglect, exposure to violence, juvenile or parental mental health or substance abuse, poverty, developmental disabilities and delinquency

8. ACT 555 Continued • Intent was to encourage collaborative efforts among local stakeholders to access needs and develop comprehensive plans to address such needs based on data driven decision making • The Role of the Children’s Cabinet shall be to facilitate creation of local (parish) C&YSPBs by offering guidance, TA to local communities and governing authorities to include resource identification, needs assessments, monitoring and evaluation and strategic planning • Only in isolated cases were primary care providers included in this process • Sabine Experience with C&YSPB

9. Other State and Regional Efforts Toward Developing School-Community Partnerships in the Past FDOE • Recovery Act DOE • Federal IDEA Mental Health Grant (2002) • Coordinated School Health Initiative (2005) • PBIS (2005) • Comprehensive Learning Supports (2008) DHH • OBH Region 7 School-Based Behavioral Health Projects (2005) • Human Service Districts organized in the 9 DHH Administrative Regions • Integration of Behavioral Health and Substance Abuse Services • CSoC (2010) • LA Behavioral Health Partnership - Magellan(2013) • Bayou Health (2013)

10. State and Federal Initiatives Supporting Integration Efforts SAMHSA-HRSA Center for Integrated Care DHH Integrated Behavioral Health Summits Louisiana Primary Care Association Rapides Foundation IBH Grant Louisiana Public Health Institute Others?

11. LPCA – Rapides Integrated Behavioral Health Project • Two year grant serving Winn, Grant, Natchitoches and Vernon Parishes • Purpose is to implement Integrated Behavioral Health in four existing FQHCs • Two sites have included school-based components

12. IBH IN CONTEXT Continuum of Integration

13. Heath B, Wise Romero P, and Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C.SAMHSA-HRSA Center for Integrated Health Solutions. March 2013

14. Key Aspects of Integrated Behavioral Health Patient-Centered Medical Home Model Based on a philosophy of primary care that is patient-centered, and provides service through a comprehensive team-based approach with coordination among providers and continuous access to care

15. Horizontal Programming • Programs and services designed to serve the entire client population with education and support (Weight Management, Stress Management, Smoking Cessation, ADHD Support, Depression Management Groups) • Akin to universal and secondary PBIS 

16. Vertical Programming • Protocols for Service Delivery are developed for specific diseases and conditions, akin to tertiary PBIS: • Procedures are developed for different categories of needs such as depression, ADHD, anxiety disorders, chronic pain, diabetes, etc. These categories are referred to as registries within the electronic medical record used to maintain patient’s charts. The registries are used to coordinate care, monitor and evaluate outcomes. • Procedures are in place for both medical providers and behavioral health specialists (LCSWs) and include the assessment process, treatment and follow up.

17. IBH Team • PCPs • Nurses • Behavioral Health Specialists (LCSWs, PhDs) • Care Coordinators • Huddles • Warm Handoffs • Registries • Stepped Care (Think RTI)

18. Implementation of Integrated Behavioral Health in Schools • Similarly to primary care providers (PCPs), school personnel including teachers, school social workers, etc. are often the first to encounter behavioral health issues and the challenges associated with them • Implementing integrated behavioral health (IBH) within the school setting connects the health clinic to school personnel and creates an opportunity for PCPs, teachers, school social workers and social workers working within the school-based clinic to have increased communication and collaboration on a regular basis in order to provide the best interventions for the students being served

19. Barriers • Philosophical silos • Political silos • Financial silos • Professional Turf • Service Gaps • Urban vs. Rural • Workforce development and training Reference the UCLA School Mental Health Project: Comprehensive Learning Supports (Howard Edelman PhD, Peggy Taylor PhD)

20. SPECIAL CONSIDERATIONS: • Prior to implementation it is important to gain support from the school board and key personnel by identifying specific needs that the school-based clinic may help address such as decreasing suspensions, decreasing absences/truancy, assisting with behavioral interventions in the classroom, and increasing parental involvement • It is also important for both the school and health clinic to develop realistic expectations of goals, and services that will be provided by the school-based clinic and the responsibilities of all parties involved • LCSWs within the school-based clinic will need to develop special skills to help them successfully manage the unique challenge of learning how to enter the school environment and facilitate a collaborative and supportive relationship with school staff

21. CROSS TRAINING • Implementing IBH in the school setting also provides a unique opportunity for cross training between professions as both academic language, medical language, and language referring to behavioral health disorders and interventions are being used in the same setting • Primary Care staff have misconceptions about Mental Health and its providers. Mental Health Staff have been trained in the Specialty Model and have a hard time adjusting to the fast pace of Primary Care • Examples of training efforts in Winn Parish: meetings and collaboration with Pupil Appraisal, PCPs, medical staff and behavioral health specialists

22. TELEHEALTH • Telehealth is an important tool for IBH in both the health clinic setting and school-based clinic setting • A grant through the Louisiana Primary Care Association currently gives 2 health clinics and associated school-based clinics access to a licensed psychiatrist through a secured connection via television on a weekly basis in the health clinic setting. • An LCSW is present with the patient or student as they participate in a psychiatric evaluation and subsequent follow up consultations • Parents and guardians also take part in the process when a child is participating in a psychiatric evaluation via telehealth

23. Telehealth continued • A written psychiatric evaluation with diagnosis and treatment recommendations, including medication, is provided via secured email to the LCSW and to a case manager at the health clinic who shares this with patient’s PCP and/or LCSW providing intervention in the school-based clinic and then scans into the chart. • PCPs and the LCSW are also able to conference with psychiatrist if needed using the telehealth setting or via phone to hold a more in depth discussion regarding patient issue if needed. • Telehealth also provides another opportunity for collaboration with school personnel. For example, the psychiatrist may request that the parent or LCSW obtain certain information from the teacher and/or inform that teacher that she may ask questions of or provide relevant observations to the psychiatrist via the LCSW .

24. Evidenced-Based Practices • Several evidenced-based practices have proven particularly effective within in primary care settings incorporating IBH, including: • Acceptance and Commitment Therapy (ACT) • IMPACT : Evidence-based Depression Care • Motivational Interviewing • Problem Solving Therapy • Cognitive Behavioral Therapy

25. Forecast For the Future • Affordable Care ACT • SAMSHA-HRSA Efforts • DHH Integrated Behavioral Health Summits, a grass roots conversation • LA Human Service Districts • Integration of Behavioral Health and Substance Abuse

26. RESOURCES • Collaborative Family Healthcare Association • www.cfha.net • LA Primary Care Association www.lpca.net • Louisiana Public Health Institute www.lphi.org • Healthcare Journal of New Orleans www.healthcarejournalno.com • SAMHSA-HRSA Center for Integrated Health Solutions • www.integration.samhsa.gov