Resource Mapping

Effective School-Community Partnerships to Support School Mental Health Comprehensive school mental health systems rely on a foundation of educators and school-employed mental health professionals (e.g. school psychologists, school counselors, school social workers), in partnership with community health and mental health professionals. States, districts, and schools often grapple with how to strategically staff a full continuum of mental health supports and services, sometimes exclusively relying on either schools or community partners. This strategy fails to leverage the strengths and resources of each system (education and health/behavioral health) and may lead to siloed and fragmented supports. This document provides an overview of the key elements of school-community partnerships and specific action steps for states, districts, and communities to foster effective collaboration between schools and community health and behavioral health partners.

When it comes to school-employed and community partners supporting school mental health: It is not either/or, it is both/and!

Background The mental and behavioral health of students is a necessary focus of education. Approximately 75 to 80 percent of children and youth in need of mental health services do not receive them.1 Of those who do receive assistance, the vast majority (70% to 80%) receive mental health services in schools.2 Further, youth are six times more likely to complete evidence- based treatment when offered in schools than in community settings3. As such, schools are often considered the natural and best setting for comprehensive prevention and early intervention services for all students, including those with and without identified education disabilities4,5 Benefits of Comprehensive School Mental Health Services Comprehensive school mental health promotes well-being and social emotional health for all students and staff, while also supporting those with mental health challenges. As our nation continues to advance equity in access to resources and opportunity, school mental health services can be a key factor in reducing disparities in academic achievement, physical and mental health, and access to quality care. Comprehensive school mental health services can reduce health disparities, especially for low income and minoritized youth.

1 U.S. Department of Health and Human Services, 2001 2 Farmer, Burns, Philip, Angold, & Costello, 2003; Rones & Hoagwood, 2000 3 Jaycox et al., 2010 4 Anglin, 2003 5 NASP, 2015

School mental health supports and services must be a critical component of any educational system on par with high

quality academic instruction.

Access to school-based mental health services improves:

• Physical and psychological safety • Academic performance • Social–emotional competence

Access to school-based mental health services reduces negative outcomes such as: • Disciplinary referrals • Dropout • Substance abuse • Involvement in the criminal justice system

Multi-Tiered System of Support The success of a comprehensive school mental health and behavioral health system relies on educators, school-employed mental health professionals (e.g. school psychologists, school counselors, school social workers), other specialized instructional support personnel, and community health and mental health providers working across a Multi-Tiered System of Support (MTSS; see Figure 1). The MTSS approach ensures that all students can access the service array, including students in both general and special education, and that all students have exposure to universal mental health supports. The number of tiers in an MTSS can vary, though many districts employ a three-tiered model.

School-Employed Mental Health Professionals and Community Partners Support Students Across a Multi-Tiered System of Support Successful and sustainable school mental health systems integrate partners seamlessly so that the full spectrum of mental health supports and services are tightly coordinated to meet student needs. Effective collaboration between school-employed and community mental health partners broadens the availability of supports and enhancing access to mental health care. The roles and responsibilities of school and community partners will differ based on unique resources and needs of school districts and the local community. Figure 2 illustrates one example of the complementary roles of schools and community partners in an MTSS. The allocation of roles and responsibilities for school- and community-employed personnel across a multi-tiered system of support is generally as follows: Tier 1: Implemented primarily by school-employed mental health professionals, and other relevant specialized instructional support personnel (e.g. school nurses) with support from community professionals Tier 2: Implemented by both school-employed mental health professionals, other relevant specialized instructional support personnel and community professionals Tier 3: Implemented primarily by community professionals with support from school-employed mental health professionals and other relevant specialized instructional support personnel

Figure 1. Multi-tiered system of support

Figure 2. Complementary Roles between Schools and Community Partners

Key Elements and Action Steps to Support Effective School-Community Mental Health Partnerships

There is no one size fits all approach to an effective school-community mental health partnership. Each partnership development should be based on the specific needs of the local community. However, there are key elements that support successful collaboration between school and community partners, including appropriate staffing, clear roles and responsibilities, and funding. These key elements, and associated action steps, are described below.

Element I: Appropriate staffing of school and community mental health professionals School- and community-employed mental health professionals both make important contributions to school mental health, but these partnerships are challenging to sustain when schools are inadequately staffed. Without enough staff, professionals are restricted to focusing on students with the most severe needs and are not able to provide critical prevention and early intervention services and supports. Most professional associations have recommended staffing ratios, which account for delivery of comprehensive wellness promotion, prevention, early identification, and intervention services at the student, classroom, and school-wide levels. Notably, school-employed mental health professionals (e.g. school psychologists, school social workers, school counselors) are trained to do this work in the school context and support the learning process in addition to mental and behavioral health. These staff are embedded in the school community, knowledgeable of school culture, and are available in a sustained capacity to work with all students and families (NASP, 2020). Appropriate staffing ratios of school-employed professionals should be coupled with community partnerships to provide both school-based services and promote access to community supports beyond the school day. One must not be a substitute for the other. Action Step I: Work toward staffing ratio recommendations Establish a plan to work towards the national recommended ratios of mental health professionals available in schools. This plan should consider how to hire to hire, retain, and increase the available workforce of school-employed mental health professionals and how community partners can augment existing staffing structures. Action Step II: Determine staffing array based on needs Based on school and community needs and availability of school and community providers, determine the best staffing array across an MTSS. Staffing determinations should be guided by student and family needs, which can be informed by a systematic needs assessment process. When establishing a school– community partnership, school teams should use data from a needs assessment to assess the fit of potential community partners. Community partners should articulate how they can enhance existing services and contribute to the school improvement plan. A school should select community partners that share mutually agreed upon goals around health, wellness, and student success. A school should only choose partners that are necessary and fit with the needs of students and families. For schools that already have community partnerships, the school and its partners should continuously assess their relationship and impact, since priorities of the school and/or community agency may change.

Needs assessment is a collaborative process among key partners (e.g.

parents, students, school administrators and staff, school- and community-

employed mental health providers) that schools can use to identify needs and assets in the school population. This process helps school mental health

teams clarify priorities, advance action planning, and allocate resources.

Resource: The School Mental Health Quality Guide: Needs Assessment and Resource Mapping

outlines best practices, action steps, examples from the field, and relevant resources.

Element II: Clear Roles and Responsibilities Partnerships between school and community providers are facilitated by clear delineation of roles and responsibilities. School staff and community partners should learn one another’s roles and responsibilities so they can effectively collaborate to support students they each serve. School-employed professionals should help community providers understand the systems of the school and legal obligations that differ from community-based care. Similarly, community- employed staff should offer education and guidance to school-employed staff if they have areas of unique expertise and knowledge related to mental health and the broader mental health care system.

School-employed mental health providers and community partners must commit to regular communication with one another to ensure all students can access to the supports they need. Effective partnerships may require a “retooling” of how school-employed mental health professionals are used to allow for more comprehensive service delivery. If students are supported by both a school-employed and a community-employed provider, a communication and data sharing plan must be developed so that all parties share the same knowledge and information about the students they are serving. Action Step I: Develop a Memorandum of Understanding Use a memorandum of understanding (MOU) or other agreements to detail the terms of the partnership. Key features of an MOU might include:

• Delineation of roles and responsibilities of the school- and community-employed professionals (e.g. prevention, promotion, and intervention services; data collection and reporting; confidentiality agreements and information sharing protocols; attendance at team meetings, trainings, and professional development)

• Outline of fiscal and resource agreement, including details of payment exchange processes

• A plan for duration and termination, including a timeline for the partnership and procedures for requesting termination by either party

Action Step II: Develop shared language and accountability systems For school-community mental health partnerships to be successful, all providers must work together to develop shared language and accountability systems that are grounded in a mutual set of goals. School- and community-employed partners can look to the school improvement plan to identify common goals for collaboration. Partners need to understand the privacy laws governing education systems (e.g. Family Educational Rights and Privacy Act) and health systems (e.g. Health Insurance Portability and Accountability Act) and ensure that any memoranda of understanding and other information sharing agreements align with legal requirements.

Resource: This joint guidance document from the

Department of Education and the Department of Health and Human Services

explain the relationship between the Family Educational Rights and Privacy Act (FERPA) statute and implementing regulations and

the Health Insurance Portability and Accountability Act (HIPAA) privacy rule.

Figure 3. Anatomy of a Memorandum of Understanding

Resource: This Memorandum of Understanding template

includes the key features and potential language to use in an agreement between school and

community mental health partners.

Action Step III: Develop a communication plan between school- and community-employed staff, families, and the community

• How will school and community providers ensure effective communication with teachers, families, other relevant stakeholders?

• How should teachers/staff/families refer students for services?

Element III: Funding to Support School-Community Mental Health Partnerships In addition to partnership quality, sustainability of school-community mental health partnerships are fueled by innovative funding strategies that include diverse funding streams. Diverse and braided funding streams prevent disruption or elimination of key school mental health services in the face of budget shortfalls or the end of a grant. Long- term sustainability plans ensure continuity of services and access to school- and community-employed providers. Diverse funding streams can improve collaboration across stakeholders as all work toward the same shared goal. Successful school-community mental health partnerships are funded by a wide array of sources, including (but not limited to):

• Legislative authorizations and federal block and project grants (e.g. Healthy Schools, Healthy Communities Program; Project AWARE; State Education Agency Grants; Promoting Student Resilience Program; and Title XX Social Services Block Grant)

• State or county funding (e.g. budget line items, local taxes, and funding to implement special programs and health initiatives

• Fee-for-service revenue from third party payers (State Children’s Health Insurance Programs, Medicaid, and commercial insurance)

• Private individual donors and private foundations (e.g. Bainum Family Foundation, Annie E. Casey Foundation, and Robert Wood Johnson Foundation)

Action Step I Map services across Tiers 1, 2, and 3 that are currently available to students and families. Outline the source, amount of funding, restrictions on use, and expected time frame for funding availability. Doing this exercise will help teams identify gaps in services and supports and determine how to sustainably integrate community-employed providers across a multi-tiered system of support.

Example from the Field An urban district in Maryland built a model that pools and leverages funding from multiple sources to support community-partners school mental health providers:

• 55% funding from fee-for-service (Medicaid, private insurance) reimbursement • 35% funding from city taxes, school district funds, and specific line items in the municipal budget • 10% funding from foundations and other grants

Action Step II: Each state has its own Medicaid plan that outlines the specific services covered, as well as the necessary qualifications for school-based providers in order to be eligible for reimbursement. Learn how you can leverage Medicaid funds to support mental health services in schools. Medicaid dollars can be used to support the salaries for of school-employed mental health professionals, and help sustain partnerships with community providers and/or agencies. Action Step III: Consider how you can leverage state and federal funding streams (e.g. Title I, Title IV-A of ESSA; IDEA) to implement or scale up comprehensive school mental health systems. In addition, explore available grant opportunities your school or district could apply for.

Conclusion Community partners should be chosen based on their ability to meet the needs of the school community. These partnerships must be routinely evaluated for effectiveness and their contribution to the overall improvement of agreed upon shared goals. It is important that all stakeholders perceive a partnership to be contributing to the overall improvement of the school and community. Periodically surveying the school and community can provide meaningful information regarding areas in which the partnership demonstrates success and in which areas it can improve.

Call to Action Talk to decisionmakers (e.g. state legislators, school board members, city council members, state or local boards of education, district school leaders, commissioners) about the importance of sustainable school-community partnerships and how these partnerships support student mental health and success in school.

Encourage decisionmakers to: • Ensure grants and state line items intended to improve school mental health service delivery advance school-

community mental health partnerships that: o supplement, not supplant, existing school-based services; o clearly articulate the roles of school- and community-employed mental health professionals; and o foster coordination and collaboration between school and community mental health professionals

• Promote efforts to address school mental health workforce shortages including funds for states/districts to recruit and retain a qualified and diverse school mental health workforce

• Carve out dedicated funding in state/local school budget for school mental health services • Carve out dedicated funding in social services budgets to help financially support school/community

partnerships • Advance efforts to provide funds to help states increase access to fully certified and/or licensed school

psychologists, especially in high need and hard to staff districts • Ensure state Medicaid plans recognize that school psychologists are appropriate providers for school mental

health services

Support for this project was provided by the Bainum Family Foundation. The views expressed in this document do not necessarily reflect the views of the foundation.

Resource The reversal of the free care policy allows schools districts to bill Medicaid for health services delivered to all Medicaid-

enrolled students, not just those with a special education plan. The Healthy Students, Promising Futures Learning Collaborative provides examples of how states are leveraging the free care policy reversal to expand access to and

resources for school health services.

Medicaid can pay mental health services for Medicaid-enrolled students. Schools and

districts can also be reimbursed for providing services outlined under Early and

Periodic Screening, Diagnostic and Treatment (EPSTD) to include screening, diagnosis, and treatment services that

include prevention and early intervention activities.