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The availability of mental health services in schools has been linked to better educational outcomes, and reduced suspensions and absenteeism.1 School leaders and health care providers agree that school-based mental health services have tangible, positive impacts on a school’s climate. It leads to a school-wide culture where students feel safe and comfortable asking for both academic and socio-emotional help. Educators should be equipped with the tools to help students in crisis, knowing they too can turn to mental health experts and that they are not expected to be educators, social workers, and disciplinarians all at the same time.
All signs point toward better outcomes for students and teachers when there is greater access to mental health care providers on-site at schools, but the services currently offered in New York City’s public schools are falling short.
Nearly 40% of the young people in the U.S. who need mental health services do not receive the treatment they need.2 The numbers are even more dire along racial and socio-economic lines, with 45% of students in poverty, 55% of Black students, and 46% of Latino students never receiving necessary mental health services. These unaddressed mental health needs pose serious consequences, placing young people at a higher risk of academic underperformance, substance abuse, unhealthy relationships, isolation, and suicide.
In New York City, nearly 237,000 children under 18 have a diag-nosable mental health condition according to the Citizen’s Committee for Children in New York. It is our duty to do all we can to facilitate mental health crisis care within a public school setting.
School is often where symptoms for mental health disorders ﬁrst become apparent. Increasing school-based mental health services will help normalize mental health treatment and allow children to connect with treatment in a setting in which they are already familiar.
New York City public school students come from over 182 countries, 42% of them speak a language other than English at home, and over 500,000 New Yorkers are undocumented and uninsured. Throughout our study, school leaders explained that they lack adequate training on how to address legal concerns of undocumented students and parents. Additionally, many school leaders shared they lack the staff needed to communicate with students who need services and information in languages other than English. Further, many school leaders say they lack clarity on what to do in case of a mental health emergency, or what even constitutes such an emergency. There is little guidance or training on crisis-based interventions, or a comprehensive referral process.
Since the 2016 presidential election, educators across the country have reported that incidents of harassment in schools have skyrocketed. With a Trump presidency, af we gear up for another 3 1/2 years of hard questions on some of the most pressing issues from immigration to police reform to reproductive rights, it is more important than ever that our schools are safe havens for our students and that teachers and other staff have the resources they need to respond when students are in emotional crises.
As a city we must renew our commitment to making sure every child has access to culturally appropriate school-based mental health services. This report examines the landscape of Manhattan’s school-based mental health services as of 2016. We spoke to mental health providers and school officials and gathered data from the Department of Education and the Department of Mental Health and Hygiene to get the full picture of mental health services available at schools across Manhattan. We identified challenges that schools and service providers face and developed recommended actions for city and state agencies to fill gaps and ensure mental health services are permanently accessible in all New York City public schools.
In New York City, school-based mental health services are licensed and put into place by multiple agencies, including the Department of Education (DOE), the Department of Health and Mental Hygiene (DOHMH), the Office of School Health (OSH) and New York State’s Office of Mental Health (OMH).
In October 2015, First Lady Chirlane McCray announced a plan called “ThriveNYC: A Mental Health Roadmap for All,” comprised of 54 initiatives aimed at reducing stigma for mental health issues and closing treatment gaps. As part of ThriveNYC, mental health resources were added to schools with low graduation rates, student achievement, and attendance, which are called Community and Renewal Schools. Eighteen of the 133 Community and Renewal Schools are in Manhattan.
Mental health services at public schools include:
School Social Workers: There are 164 Manhattan public schools that have in-house social workers, which they primarily pay for through their students’ individualized education plans (IEPs). These plans are to provide mandated services to special needs students, not to fund services for the general population. Some funding also comes through specific City Council or DOE initiatives focused on providing students with socio-emotional support.
In Manhattan, we have over 177,000 students, yet only 221 school-based social workers in just 164 schools. That breaks down to roughly one social worker for every 800 students. Citywide, the DOE employs 1,183 social workers in New York City public schools, or approximately one for every 900 students.
School-based clinics, which fall into two categories:
Article 28 clinics: There are 103 Manhattan public schools with Article 28 clinics, which are regulated by OSH and are a collaborative effort between the DOE and DOHMH. Article 28 clinics are primarily located in under-served neighborhoods and provide on-site primary care to students.3
Article 28 clinics require a fully operational medical room with internal constructions, plumbing, and electricity, and a staff with multi-disciplinary teams. Teams can include nurse practitioners, physician assistants, and physicians. Many Article 28 clinics also have full-time or part-time licensed social workers who provide mental health services.
Since 2012, New York State has implemented a “carve out” for Article 28 clinics. This allows Article 28 clinic providers to bill New York State directly for mental health services provided, and allows the state to more efficiently process reimbursements.
In October 2017, the State will transition Article 28 clinics into managed care. A recent study by the Children’s Defense Fund found that in New York State, Medicaid reimbursements comprise more than 89% of Article 28 clinics’ third-party revenue in New York.4 The study compared current Medicaid reimbursement rates for primary care services to rates that will be set under a managed care payment structure and found that state-wide this could lead to a loss of $16.2 million in revenue.5
New York State’s intent for Medicaid redesign is to expand access to high-quality care for all New Yorkers, so it is imperative that the transition to managed care for Article 28 clinics is done in a way that does not threaten the financial sustainability of these clinics.
Article 31 clinics: There are 62 Manhattan public schools that currently have Article 31 clinics, which are licensed and regulated by OMH. These clinics are satellites of “primary” Article 31 clinics and by definition they host counseling sessions, are staffed by licensed social workers, and operate in a confidential space with floor to ceiling walls. They offer assessments of mental health needs, interventions, consultations with families, and training services for school staff. These clinics are at a disadvantage because they did not receive the carve-out or additional state funding that Article 28 clinics received.
Mental Health Consultants: There are 114 Manhattan public schools that have mental health consultants. These mental health consultants are managed by OSH, though they are funded by the Mayor’s Fund to Advance NYC. The consultants are part of a ThriveNYC initiative. Over the past two years, the DOE and DOHMH have hired 100 mental health consultants for public schools.6 Each consultant is a licensed social worker who provides mental health consulting services for 10 school campuses, provides schools support for clinical assessments and interventions, co-designs and co-implements training and outreach for school staff, and helps schools develop referral networks for students who need continuing care.
Schools without their own mental health clinics rely on consult-ants, but this isn’t a satisfactory solution. Over 55,000 students, one- third of Manhattan’s school population, only have access to consultants. But each consultant is tasked with serving 10 campuses, so that some- times a single consultant is responsible for serving up to 8,000 students.
With only one provider per 8,000 students, are our young people getting the individual attention they need?
Mobile Response Teams (MRT): Seven Manhattan public schools currently have another variation of consultants–MRTs–which are managed by OSH and funded by the State Office of Mental Health. They are mobile teams which schools can call during crisis situations. They offer assessments, consultations, professional development for teachers, parent trainings, and referrals for treatment elsewhere in the community.7
To get a better picture of the impact that mental health consultants have in Manhattan public schools, we conducted a few interviews with school leaders, some from schools which have had their mental health consultants for a longer period of time than others. Out of the 118 schools with consultants, we randomly selected 15 to survey. We spoke with varied staff, including guidance counselors, school psychologists, principals, and assistant principals. Some takeaways included:
• Many guidance counselors and some assistant principals were not aware that their school had been assigned a mental health consultant.
• Staff in multiple schools expressed that the mental health consultant’s impact was minimal and that the resources they provided could have easily been found online.
• One assistant principal from a K-8 school shared that a majority of the staff felt that arranging for meetings with the consultant was bureaucratic and took a long time. Once a meeting was set up with the consultant, school staff described the training as a waste of time. That school ended up having to supplement the training provided with training from their full-time guidance counselors.
• Several schools said that the training they received was rudimentary and formatted like an information session, rather than a more constructive brainstorming session.
• The majority of the schools we spoke to shared that their mental health consultant had only been to campus a handful of times and had not done any training with the staff.
• None of the schools we spoke to mentioned consultants helping create a school-wide metal health plan, or identifying specific priority areas within the school.
All of the schools we spoke to mentioned that on-site support is desperately needed during moments of crisis. While mental health consultants are meant to connect school staff and administrators to mental health resources, there are too few being tasked with too much. In order to change school culture and develop emergency protocols, it is vital that these services become ingrained in the school—with licensed social workers having direct access to students, teachers, and administrators. By design, consultants cannot do all of those things while not being a part of school staff or being on-site full time.
No steady stream of funding exists for schools that are not Community or Renewal Schools. School principals who are interested in hiring school-based social workers or starting Article 31 clinics have to pay for the services out of their own school budget, and so are required to make programmatic trade-offs if they want to make providing school-based mental health services a priority.
If we are serious about focusing on our students’ socio-emotional development, we must address the barriers school leaders and healthcare providers face at the school, city, and state levels that prevent them from providing services to every student in need.
School-based health and mental health clinics operate under independent healthcare providers that directly enter into an agreement on terms of services with schools and provide services through satellite clinics. These mental health providers include hospital centers, community health providers, mental health agencies, and youth serving community-based organizations.
Clinics are primarily funded through reimbursements from students’ health insurance, which is usually Medicaid.
Medicaid reimbursement rates on average only cover about 60% of the actual cost of rendering services. Providers have repeatedly expressed concerns that relying on Medicaid reimbursements as the primary source of funding is not sustainable.
In order to truly integrate school-based clinics into the fabric of the school, it is essential that providers engage in outreach and training work every day, meeting with parents and teachers, facilitating school-wide mental health trainings, doing in-class presentations, holding group sessions for students, and becoming a visible presence in the school. Unfortunately none of these activities essential to bringing about change in school culture are reimbursable by Medicaid or other health insurance.
With most schools only open ten out of twelve months, providers only bill hours during the time school is in session. While school based mental health providers come up with various ways to maintain student connection during breaks, the discontinuity—inherent in school calendars—adds to the need for institutional support structures. On average, school-based clinics generate between 50-70% of the revenue necessary to sustain their operations.
In 2011 Governor Cuomo issued an executive order to create the “Medicaid Redesign Team,” aimed at restructuring Medicaid to create a more efficient and effective way to deliver essential services at lower costs. One part of the redesign includes managed care, which “provides for the delivery of Medicaid health benefits and additional services through contracted arrangements between state Medicaid agencies and managed care organizations (MCOs).” In practice this means that the rates of reimbursement for services and scheduling of payments will be determined by MCOs, which have set lower payment rates than those that providers receive via the fee-for-service payment model. This causes providers to further fear for their financial sustainability.
Understanding the inherent challenges and balancing them with the ultimate pay-off for student well-being, we have a series of recommendations that we hope will lead to greater access to the mental health care that our students need and deserve.
The Department of Education should…
Create funding structures to pay for school-based mental health services for all schools that are not designated as Community or Renewal schools. School leaders should not be asked to make trade-offs between providing emotional supports and academic programming for students.
Commit to providing school staff with bystander intervention and anti-racism training. In order to address both heightened and new types of bullying, discrimination and harassment in schools, it is essential that school staff, including educators, guidance counselors and social workers all have the necessary tools to talk about race and use necessary intervention tactics in a nuanced way.
Help schools develop a targeted resource list and referral plan so there is a clear path in moments of crisis. These must go beyond generic phone numbers for a nearby mental health facility. Schools should develop working relationships with a range of culturally appropriate organizations and professionals who are readily available.
Provide professional development for school staff on mental health issues.
Help schools develop communications plans, bringing together teachers, administrators, and guidance counselors to create a safe culture in school for students who may be dealing with trauma. School staff should be in contact with relevant agencies that students and their families come in contact with, including the Administration for Children’s Services and the Department of Corrections, to ensure that school staff are getting all relevant information to address students’ needs.
Waive the permit fee imposed on school-based clinics for operating outside of regular school hours. With schools in session only 40 out of 52 weeks of the year, providers face challenges in building up large enough caseloads to financially sustain their operations. Allowing school-based clinics to operate year-round will also allow providers to hire year-round clinicians rather than school-year clinicians, who have a higher turnover rate. This will also ensure services are available to students year round.
Conduct a pilot study into the impact, effectiveness, and outcomes of school-based mental health centers with DOHMH and the Mental Health Council established by ThriveNYC. Such a study could examine suspension, graduation, and attendance rates among comparable student populations in schools without school-based mental health services. n Create a mechanism for off-site supervision of social work interns for schools without a school-based social worker, so interns can provide mental health services during their field placements.
Ensure that all schools have identified space for private counseling.
The State should…
Keep Medicaid reimbursement rates constant for Article 28 clinics for a two-year period so providers can adapt to the new billing structure under managed care.
Create permanent avenues for operational funding to finance essential preventative and administrative services, such as classroom-based outreach and teacher training.
Create a centralized billing system that enables school based mental health centers to bill insurers in an efficient manner.
City agencies that work with at-risk populations should...
Make funding available for special needs therapy services in public schools. Agencies including the Department of Corrections and the Department of Probation should ensure funding for public school children who are affected by parental incarceration, foster care placement, homelessness, or bullying.