This Web site is a component of the SAMHSA Health Information Network
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This Web site is a component of the SAMHSA Health Information Network. |
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Chpater 33.0 Administrative Arrangements for the Delivery and Coordination of Mental Health Services in SchoolsThis chapter presents survey findings on the prevalence of various administrative arrangements for the delivery of mental health services in U.S. public schools. Survey questions were based on a number of “delivery mechanisms and formats” described by the Policy Leadership Cadre for Mental Health in Schools (2001) and summarized in Chapter 1. These formats include:
Since these models are not mutually exclusive, survey questions were designed to measure the features or dimensions of each model, rather than explicitly measuring the existence of each model as a separate entity. The dimensions include the types and combinations of staff providing mental health services to students (addressed in the previous chapter); administrative arrangements for delivery of services, including the use of school- or district-based staff, and of community providers; locus of responsibility for various administrative functions at the district or the school level; and ways in which services are coordinated internally and across delivery systems. The survey attempted to capture the extent to which schools and school districts utilize their own mental health staff as opposed to contracting for these services with community-based providers. The survey also queried respondents on a variety of administrative functions (e.g., funding and staff allocation, hiring, supervision, staff training, contract monitoring); whether the school, district, or another unit had responsibility for mental health; and whether or not there were any differences between general education and special education. Finally, several questions elicited information on coordination and referral practices internal to the school (e.g., between teachers and mental health providers) and between the school and other child-serving systems in their communities, such as juvenile justice, child welfare, and community mental health. 3.1 Contracting ArrangementsAbout one third of school districts reported that they exclusively use school or district-based staff to provide mental health services. About one quarter of school districts only contract with outside providers for mental health services in the district. About one third of schools combined school and district-based staff, either together or in some combination with outside providers. Almost half of school districts overall (49 percent) used contracts or other formal agreements with community-based organizations and/or individuals to provide mental health services to students (Appendix C, District Tables 3, 3A). These contractual arrangements augment the service delivery capacity of districts by making other child-serving systems available to schools to provide services. Contractual arrangements are most common in large districts. 9 Because the survey focused on formal or contractual arrangements, the results may underreport the professionals to whom students may have access in the community. Individual schools were also asked about their staffing arrangements. For each mental health service provided by schools, respondents were asked if school- or district-based staff, community-based staff via a formal arrangement, or both provided the service. The survey found that in most cases, when schools provided a particular service, it was more likely to be provided by the school or district rather than by a community-based provider, with the exception of medication management, which was slightly more likely to be provided by a community-based provider (Exhibit 3.1).
Formal Arrangements Between Schools and Community-Based Providers In 2002–2003, over half of schools reported that they had formal arrangements with one or more community-based organizations or individual providers for student mental health services. The most frequent arrangement was with county mental health agencies, followed by community health centers, individual providers, and juvenile justice systems (Exhibit 3.2). Arrangements with local hospitals and faith-based organizations were not as common.
Middle schools were more likely than elementary or high schools to have contractual arrangements with community providers and were significantly more likely to have such agreements with community health centers and juvenile justice agencies (Appendix C, School Table 11). Many of the community agencies (62–86 percent) provided their services on site, in the school (Appendix C, School Table 12). The exceptions were local hospitals and community health centers or clinics, which were more likely to provide their services in the community only. The survey included an open-ended question concerning schools’ most successful strategies for improving the mental health of students. The most frequently mentioned strategy was the availability of in-school mental health providers who were employed by the school or district. Collaboration with outside agencies was also considered a valuable strategy.3.2 Mental Health Units and School-Based Health CentersThe literature and survey pilot testing revealed variability in the terminology used to describe various service delivery mechanisms. The survey attempted to use terms that would be universally understood by respondents. Key features of a school-district–operated mental health unit are that they are operated and financed by the district, or the district organizes a multidisciplinary team into a “unit” to provide mental health services (Policy Leadership Cadre, 2001). School-based health centers can be sponsored by organizations such as hospitals, community health centers, and nonprofit organizations. The literature showed that some districts operate their own mental health units or clinics that serve one or more schools; others have their own school-based health centers (Policy Leadership Cadre for Mental Health in Schools, 2001). In this study, district respondents were asked if they operated a mental health unit or clinic serving multiple schools. Only two percent of school districts reported that they had such district-operated mental health units or clinics (Appendix C, District Table 3). School respondents were asked if they had an agreement with a “school-based health center operated by a community-based organization” to provide mental health services to their students. These health centers may be different from school-based health centers that are members of the National Assembly on School-Based Health, so the estimates of the number of such health centers in the nation may differ. Seventeen percent of schools nationwide had such an arrangement. School-based health centers were more often reported in middle schools (23 percent) than in elementary schools (16 percent) or high schools (14 percent). They were also more prevalent in urban schools (22 percent) than in suburban or rural schools (15 percent each) (Appendix C, School Table 11).3.3 Administrative Functions in School Mental HealthThe literature review revealed a model for school mental health in which schools were given the autonomy to determine the types of mental health staff they hired and the overall allocation of mental health resources. The survey sought to determine the locus of control for various administrative functions pertaining to school mental health. Districts, rather than schools or other entities such as collaboratives most commonly had authority for administration of mental health services (73 percent) (Appendix C, District Table 2). Authority for such functions was less commonly located in schools (22 percent) or intermediate units, collaboratives, or cooperatives (14 percent). 10 The model in which schools or clusters of schools determine mental health staffing was fairly uncommon, reported by only 10 percent of districts (Appendix C, District Table 2). There were no differences between general and special education in the locus of authority for administration of mental health services (Appendix C, School Table 6). Nationally, the most common practice reported by districts was to administer mental health services for general and special education students together (67 percent). In other words, mental health services tended to be housed in the same administrative unit regardless of the special education status of the student requiring mental health services. There were some differences noted by district characteristics, however. For example, the largest districts (those with 16 or more schools) were slightly more likely than smaller districts to administer mental health services for general and special education students separately (39 percent versus 24 percent; Appendix C, District Table 1B). High schools (12 percent) were more likely than middle schools (5 percent) and elementary schools (5 percent) to manage mental health services for special education students separately from general education students (Appendix C, School Table 5).3.4 Coordination and Referral PracticesThe survey queried respondents on practices regarding coordination of services within the school or district, as well as with community-based organizations and providers. Within the school setting, the survey sought information on the frequency of various strategies used by mental health staff, special education staff, and classroom teachers to coordinate activities and services for students in the school. Coordination strategies and their frequency of use are depicted in Exhibit 3.3. Schools varied in the frequency with which they used these strategies. Approximately one third of schools rarely or never held interdisciplinary meetings among mental health staff, conducted joint planning sessions between mental health and other staff, or shared mental health resources with each other. The exception to this was informal communication, which occurred weekly in one third of schools. At the other end of the continuum, however, 40 percent of schools held monthly or weekly interdisciplinary meetings and planning sessions, and one third of schools held weekly or monthly joint planning sessions between mental health and other school staff as well as weekly informal communication. Exhibit 3.3 Percentage of Schools Using Strategies To Coordinate Mental Health Activities and Services Within Schools, 2002 –2003 11
Coordination With and Referral to Community-Based Providers Many schools, even if they do not have formal agreements with community organizations to provide mental health services, will refer students to community agencies for such services. All school respondents were asked to report their routine referral and coordination practices with community providers. Use of passive referrals (e.g., distributing brochures, lists, phone numbers of providers) was the most common practice, used by three quarters of schools (Appendix C, School Tables 14, 14A). Nineteen percent of schools used passive referrals as their only routine practice. Active referrals (e.g., staff completing forms with families, making calls or appointments, assisting with transportation) were reported by over half (53 percent) of schools, and follow-up with families and providers was also practiced by over 40 percent of schools. Forty percent of schools reported that their staff attended team meetings with the staff of community providers. Schools that had agreements with community-based organizations were more likely than schools without such arrangements to coordinate service planning across agencies: 50 percent of schools with agreements had staff attend team meetings with community providers as opposed to 29 percent of schools without agreements. One theme that emerged from open-ended comments in response to a question on their most successful strategies for improving the mental health of students was the importance of developing positive formal and informal relationships with community providers. 3.5 SummaryThe findings on the administrative arrangements for the delivery of school mental health services, as they relate to the formats described in the beginning of the chapter, suggest that school districts were most likely to hire their own staff to provide mental health services in schools, but that contractual arrangements were quite common, found in about half of school districts. The use of district-operated mental health units or clinics appears to be relatively rare, reported in a small minority of schools, but 17 percent of schools reported having an arrangement with a community-operated, school-based health center (not necessarily located in the same school). 12 Districts were more likely than schools or other units to control various administrative functions such as hiring and supervision, and districts tended to administer mental health services for all students in one unit, rather than administering mental health services for students in special education separately. There was variation in the degree to which various strategies for coordinating mental health services were used by schools. It was striking that about one third of schools rarely or never used any of the strategies listed in the survey. Many schools reported making referrals to community-based services, but passive referrals appear to be the most common practice. On the other hand, close to half of schools reported that their staff attend team meetings, suggesting that there was some level of commitment on behalf of schools to collaborate with community providers. It was not possible in this baseline study to determine the prevalence of “comprehensive … integrated” models that would resemble a system of care, but there is evidence to suggest that efforts are being made to enhance the service array via contractual and other formal arrangements, and that some collaboration is occurring among child-serving systems.
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