Integrated Behavioral Health:Connecting Community and School Services

Lauren Arnold LCSW

James Wagley LCSW-BACS

Vanguard Behavioral Health Consultants LLC

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.

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

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)

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

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

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

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

Other State and Regional Efforts Toward Developing School-Community Partnerships in the Past

FDOERecovery Act

DOEFederal IDEA Mental Health Grant (2002)Coordinated School Health Initiative (2005)PBIS (2005)Comprehensive Learning Supports (2008)

DHHOBH Region 7 School-Based Behavioral Health Projects (2005)Human Service Districts organized in the 9 DHH Administrative RegionsIntegration of Behavioral Health and Substance Abuse ServicesCSoC (2010)LA Behavioral Health Partnership - Magellan(2013) Bayou Health (2013)

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?

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

IBH IN CONTEXT

Continuum of Integration

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

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

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 

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.

IBH Team

PCPs

Nurses

Behavioral Health Specialists (LCSWs, PhDs)

Care Coordinators

Huddles

Warm Handoffs

Registries

Stepped Care (Think RTI)

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

 

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)

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

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

 

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

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 .

 

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

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

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