Department of Health and Human Services: Enhancing School-Based Health Services Program

The goals of the CoIIN-SBHS Program are to: (1) improve the quality of school-based health centers (SBHCs) and comprehensive school mental health programs (CSMHPs); and (2) expand the number and improve the sustainability of SBHCs and CSMHPs through the spread of innovative and practical policy and finance approaches.  The first program goal will be addressed by developing and implementing standardized national performance measures, and both program goals will be addressed by use of learning collaboratives to set common aims and benchmarks, develop coordinated strategies, apply rapid test cycles with real-time data, and support capacity building.  The four-year program target for expanding SBHCs and CSMHPs has been set as a 30% increase in their numbers.

The CoIIN-SBHS Program focuses specifically on school-based health centers (SBHCs) and comprehensive school mental health programs (CSMHPs).  As defined by the Children¿s Health Insurance Reauthorization Act of 2009 (§ 2110(c) (42 U.S.C. 1397jj), a school-based health center (SBHC) denotes a health clinic that 1) is located in or near a school facility of a school district or board or of an Indian tribe or tribal organization; 2) is organized through school, community, and health provider relationships; 3) is administered by a sponsoring facility; 4) provides through health professionals primary health services to children in accordance with State and local law, including laws relating to licensure and certification; and 5) satisfies such other requirements as a State may establish for the operation of such a clinic.  The sponsoring facility includes any of the following: a hospital, public health department, community health center, nonprofit health care agency, school or school system, or a program administered by the Indian Health Service or the Bureau of Indian Affairs or operated by an Indian tribe or a tribal organization.  The CoIIN-SBHS Program focuses on SBHCs that serve students attending public elementary and/or secondary schools.

Although 76% of school districts in the United States provide services to assist students who are experiencing personal or social problems that can affect school performance, delivered either by school mental health or social services staff, or through an arrangement with a community organization not on school property (60% of districts)[1], the CoIIN-SBHS Program focuses on comprehensive school mental health programs (CSMHPs), which provide a full array of tiered services,[2],[3],[4] including universal mental health promotion activities, as well as selective prevention and indicated early intervention services, such as clinical assessment and treatment. They are built on collaborative partnerships between school systems and community programs,[5] so that the efforts of school-employed mental health professionals are augmented in a planned, purposeful way by community mental health programs, such as community mental health centers, hospitals, and universities, to improve student behavior, reduce barriers to learning, increase access to mental health care, and improve both student attendance and academic achievement. In addition, CSMHPs use evidence-based practices[6],[7],[8],[9] to the extent possible and attempt to address quality improvement.[10]  Only 10% of school mental health programs, however, are estimated to meet this definition of a CSMHP.[11]

The CoIIN-SBHS Program is grounded in the diffusion of innovation principles (communicating innovation through effective channels over time ). [12]  It will harness the successes of early adopters, champions, and opinion leaders to spread effective innovations and practices. The CoIIN-SBHS Program also capitalizes on methods demonstrated to be effective to support improvement for, and growth of, the entire field of school-based health services. 

Program objectives for each goal of the CoINN-SBHS Program are outlined below.

Program Objectives for Goal 1: Improve the quality of SBHCs and CSMHPs

Develop and implement standardized national performance measures for school-based health services that recognize and address the complex nature of varying mental health, economic, cultural, language, and special needs issues faced by SBHCs and CSMHPs.It is expected that the applicant will provide a plan to meet the following sub-objectives of the CoINN-SBHS Program:

By the end of year 1, develop a consensus among SBHCs and CSMHPs for standardized performance measures for a voluntary national performance measurement system.
By the end of year 2, collect data on national performance measures from a minimum of 25% of all SBHCs and CSMHPs in the United States, regardless of their operational funding sources.
By the end of year 4, collect data on national performance measures from a minimum of 50% of all SBHCs and CSMHPs in the United States.

Develop a collaborative improvement and innovation network (CoIIN) to support quality improvement in school-based health services (SBHCs and CSMHPs) and measure improvement using CoIIN-designated metric objectives.In general, the CoINN will develop a vision for evidence-based service delivery in the key selected topics in school-based health services; guide development of the specific recommended change concepts and change packages likely to improve performance when applied and customized locally; facilitate learning across teams; and provide leadership for the spread of activities.

Collaborative improvement activities should include:

Using learning collaboratives as a key means for setting common goals and benchmarks, developing coordinated strategies, and applying rapid test cycles with real-time data in order to drive quality improvement and to support capacity building and expansion of SBHCs and CSMHPs.

Partner with SBHCs and CSMHPS to collaborate and learn from each other and from an expert faculty to advance the common aim of improving the quality of school health service programs.
Identify topics and design change packages that have the potential for high impact, are feasible, and are aimed at closing the gaps between knowledge and practice.
Facilitate progress through the training and coaching of partnering SBHCs and CSMHPs around performance measurement and use of data for enhancing effectiveness, efficiency, productivity, and quality, as well as the content of the issues to be addressed.
Use what is learned from the learning collaboratives to spread and diffuse innovative approaches to accelerate improvement across the field of SBHCs and CSMHPs.
Recruit SBHCs and CSMHPs (minimum of 25 sites) that will assemble teams for collaborative learning, as well as participate in performance partnerships.

Forming a multidisciplinary project advisory and planning group to include:

Experts with knowledge of child and adolescent physical and mental health and of SBHC and CSMHP practice.
One or more improvement advisors with experience in the Model for Improvement,[13] who teach and coach teams in improvement methods and how to apply them in local settings.
Representatives of educator, school administrator, parent, student and other key stakeholding perspectives.

Designing and supporting a web-based system that meets the needs of the CoIIN-SBHS Program, including but not limited to real-time data collection by partnering SBHCs and CSMHPs, and creation of a virtual workspace for collaborative teams to store data and information.
Training partnering SBHC and CSMHP teams in learning related to data collection, data analysis, data use, quality improvement methods, evidence-base interventions, and content areas targeted for quality improvement.
Convening all team learning sessions meetings and providing ongoing technical assistance to participating teams during action periods based on the Institute for Healthcare Improvement (IHI) Breakthrough Series collaborative model.
Based on experience in the learning collaborative process, developing and implementing a dissemination and diffusion of innovation plan that includes the population, goals, improvements, measures, and communication methods and multiple channels to be used for communication with opinion leaders, peers, and other key audiences.

Program Objectives for Goal 2: Expand the number and improve the sustainability of SBHCs and CSMHPs through the spread of innovative and practical policy and finance approaches

Develop a collaborative improvement and innovation network (CoIIN) to support capacity building in school-based health services (finance and policy) and measure improvement using CoIIN-designated metric goals (see objective 2 under the first program goal for information on collaborative improvement activities).
Develop information on how to leverage various funding mechanisms (e.g. Medicaid), to support the existence and sustainability of SBHCs and CSMHPs.
Develop and implement strategies for local communities to expand and increase the number of SBHCs and CSMHPs nationally.
Provide technical assistance nationwide to states, communities, and organizations regarding policy and finance approaches for developing and sustaining SBHCs and CSMHPs.
Work cooperatively and collaboratively with other organizations funded by Federal agencies that address school health and safety or mental health of children and adolescents (e.g., SBHCs supported by HRSA¿s Bureau of Primary Health Care; the National Coordinating Committee on School Health and Safety, which is administered by the Maternal and Child Health Bureau; the Safe Schools/Healthy Students Initiative, which is co-supported by the Department of Health and Human Services¿ Substance Abuse and Mental Health Services Administration, Department of Education, and Department of Justice; the Supportive School Discipline Initiative, which is co-administered by the Departments of Education and Justice; and programs supported by the Centers for Disease Control and Prevention).
Disseminate findings to school administrators, policy makers, and practitioners via reports and issue briefs, professional publications, presentations at meetings, webinars, and other technology to support expansion and sustainability of SBHCs and CSMHPs, which depend on the spread of innovative and practical policy and finance approaches. Topics related to financing and sustainability will include Medicaid, the Affordable Care Act, the Title V Maternal and Child Health Block Grant, and other public and private resources.

[1] Demissie Z, Parker JT, Vernon-Smiley M. 2013. Chapter 6, Mental Health and Social Services: Results from the School Health Policies and Practices Study 2012. Department of Health and Human Services, Centers for Disease Control and Prevention.

http://www.cdc.gov/healthyyouth/shpps/2012/pdf/shpps-results_2012.pdf#page=71

[2] Kratochwill TR, Albers CA, Shernoff ES. 2004; Child Adolesc Psychiatr Clin N Am 13(4):885-903. School-based interventions.

[3] Hoagwood K, Johnson J. 2003; J School Psychol. 41(1):3-21. School psychology: A public health framework I. From evidence-based practices to evidence-based policies.

[4] Strein W, Hoagwood K, Cohn A. 2003; J School Psychol 41(1):23-38. School psychology: A public health perspective II. Prevention, populations, and systems change.

[5] Weist MD, Mellin EA, Chambers KL, Lever NA, Haber D, Blaber C. 2012. Challenges to collaboration in school mental health and strategies for overcoming them. J School Health 82(2):97-105.

[6] Kazak AE, Hoagwood K, Weisz JR, Hood K, Kratochwill TR, Vargas L, Banez GA. 2010. Am Psychologist 6592):85-97. A meta-systems approach to evidence-based practice for children and adolescents.

[7] Kratochwill TR. 2007. Am Psychologist 62(8):826-43. Preparing psychologists for evidence-based school practices.

[8] Kratochwill TR, Albers CA, Shernoff ES. 2004. Psychiatr Clin N Amer 13(4):885-903. School-based interventions.

[9] George M, Taylor L, Schmidt SC, Weist MD. 2013. Psychiatr Services 64(5):483-486. A review of school mental health programs in SAMHSA¿s National Registry of Evidence-Based Programs and Practices.

[10] Weist MD, Youngstrom EA, Stephan S, Lever N, Fowler J, Taylor L, McDaniel H, Chappelle L, Paggeot S, Hoagwood K. 2014. J Clin Child Adolesc Psychol 43(2):244-255. Challenges and ideas from a research program on high-quality, evidence-based practice in school mental health.

[11] Weist MD, Goldstein J, Evans SW, Lever NA, Axelrod J, Schreters MD, Pruitt D. 2003. J Adolesc Health 32S:70-78. Funding a full continuum of mental health promotion and intervention programs in the schools.

[12] Rogers E.  Diffusion of Innovations. (4th edition) New York: The Free Press, 1995.

[13] The Breakthrough Series: IHI¿s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003. (Available on http://www.IHI.org)