Bringing Care
to the Classroom

Schools can be a safe, reliable point of access for Michigan kids in need of behavioral health treatment. The Michigan Health Endowment Fund supports a range of school-based behavioral health initiatives, and we've seen particular promise in collaborations that use telehealth solutions. As virtual visits become ever more common, established community healthcare clinics and schools can partner to use technology to help more students get the care they need.

One example of a successful telehealth model is the Family Medical Center of Michigan’s (FMC) partnership with rural schools. FMC, a Federally Qualified Health Center (FQHC), partners with area schools lacking access to community behavioral health services to provide telepsychiatry to students alongside in-person, social-worker-led therapy. This program proved to be financially sustainable, scalable, potentially replicable, and is especially relevant for rural communities or other regions with few practicing psychiatrists or therapists.

This case study profiles what FMC did and what they learned. We've also included some templates and documents that we think might be helpful in designing similar programs. The Health Fund hopes this serves as an inspiration, a starting point, and a useful set of tools for other FQHCs and education professionals to learn from and adapt this important work.

This project grew from the strategic goal of FMC’s CEO Ed Larkins and its Board of Director to provide services in rural schools via telehealth. Based on this strategic goal, Audrey Smith, COO, and Jessica Parsil, Director of Behavioral Health Services, developed and implemented FMC’s school-based telehealth project focusing on behavioral health services. Thank you for leading the way in this important project.

The Family Medical Center of Michigan (FMC) is a Federally Qualified Health Center providing primary care, behavioral health, OB/GYN, physical therapy, pharmacy, and dental services in southeast Michigan. Through this project, FMC wanted to improve access to behavioral health services for school-aged children in rural southeastern Michigan. Specifically, they aimed to address attention deficit hyperactivity disorder, depression, anxiety, trauma, and substance use disorders and improve school culture around behavioral health services. With the grant from the Michigan Health Endowment Fund, FMC implemented a combination of onsite and telehealth behavioral health services in several schools, including elementary, middle, and high schools across its service area.

Over the 2016–17 and 2017–18 school years, this FMC initiative provided behavioral health services to 381 students across seven locations. Following the grant period, FMC doubled its reach and expanded to urban settings as well. To date, FMC has worked with more than 1,131 students across 30 locations, providing 11,288 therapy sessions and 2,240 telepsychiatry appointments. By providing these services in schools, FMC minimized access barriers and decreased the amount of time students spent out of the classroom. The project successfully improved and, in many cases, created access to necessary behavioral healthcare, including therapeutic treatment, psychiatry, and medication management.

Importantly, the response from school officials, teachers, parents, and students was overwhelmingly positive. The project not only provided vital services to students in need; it also strengthened community collaboration and enhanced teacher knowledge of and access to services for students, all while creating a sustainable and replicable model for partnerships between FQHCs and schools.

Securing Board Approval

Like many health clinics, FMC relies on its board of directors to approve and ultimately champion new initiatives and programs. FMC staff used district and socioeconomic data to present the stark realities of the lack of local behavioral healthcare options for students in rural settings. Faced with the disparity in access to care for these children, Board members were quick to approve the idea for a hybrid in-person/virtual approach and became advocates and essential partners in the project.

Following the grant period, FMC went back to its board seeking approval to expand to urban school settings as well. This time around, FMC staff focused on the socioeconomic determinants of health that prevented many students from seeking behavioral healthcare outside of the school setting. Making the case for this expansion required board members to understand that while urban settings may be home to more behavioral health providers, students from schools with high rates of free and reduced lunch eligibility, lower academic achievement, and racial health disparities could also benefit immensely from onsite services.

In addition, FMC staff met frequently with school leaders to fine tune the process for student referrals, as well as gather feedback from staff. Throughout the year, FMC staff attended professional development sessions and teacher staff meetings. They also provided classroom presentations on coping with anxiety and managing inattention and described how to access additional support through the school behavioral health clinic.

FMC staff found that the timing and frequency of the information sharing was very important for staff and parent education to ensure appropriate referrals and engagement. In the first year, FMC missed the start of school when orientations and staff professional development took place, missing key opportunities to introduce the new program to staff and parents. But in the second year, FMC was able to be part of Kindergarten Round-up and school open houses to share information about the availability of school-based behavioral health services.

LESSONS LEARNED

• Leverage opportunities where school staff and parents will already be present to advertise and provide information about the new program.
• Recognize that different strategies work in different schools - build relationships with school staff and administrators to understand each school’s culture and to identify advertisement and referral strategies that will work best for each.

FMC initially began by using paper referrals, which school staff sent to the medical support coordinator. But the paper format created communication challenges: the support coordinator didn’t receive referrals until they were physically present at the school, and there was no system to communicate with schools regarding referral status in the enrollment process, nor a way to share what communication took place with families.

FMC and the schools worked together to develop an online referral system using Google Forms, and to track referrals using Google Docs. With this approach, the support coordinator could see a referral as soon as it came into the system, and all authorized staff could see the status of each referral including actual and attempted communications with families. In order for Google Docs to be HIPAA compliant, stored data must be encrypted, including during uploading and downloading.

FMC initially tried to have parents complete registration and consent forms in advance of their child’s first appointment, but the response rate was low. Ultimately, they found that having parents complete the forms onsite at the time of the first appointment was the best method for obtaining consent. The form covered future visits, so parents did not have to be present beyond the first meeting.

lessons learned

• Create a parental consent form that covers participation for the whole year, which minimizes participation barriers by requiring parents to only attend the first intake meeting.
• Address referral issues early and work with partners to develop joint solutions. Ensure there are regular opportunities to discuss referrals with school staff, including information about the referral process, who to refer, and where to refer students if not eligible for care through the school-based program.
• Design a HIPAA-compliant online referral system that allows participating staff to access information remotely and in real-time.

Beyond simply providing behavioral healthcare, implementing the program required continual considerations around scheduling, quality control, and how to sustainably grow the program.

SETTING THE SCHEDULE

FMC worked with each school to determine the days and times FMC staff were available at a specific location. The demand for services was high enough that some schools wanted FMC staff there every day and as the project progressed, staffing schedules were adapted to align more closely with each school’s needs. The medical support coordinator played a crucial role in building relationships with school staff and teachers to ensure students were able to attend sessions with the social worker.

Adaptability is key for both onsite positions. FMC found it most beneficial to the students to be extremely flexible in the timing of these appointments throughout the day. Building relationships with school staff and understanding students’ academic, social, and behavioral health needs is essential to the success of the program.

Regular Reviews

To ensure high quality care was delivered, FMC conducts a bi-monthly peer review process. This process allows FMC to review complex cases, evaluate adherence to treatment plans, and ensure that all therapeutic options are considered, especially in cases where the psychiatrist prescribed medication. Peer consultation and review are important components of any clinical practice for both the clinicians and clients. FMC incorporates regular opportunities for case discussion and treatment review to both support the staff and to make sure the needs of students are met.

Summer Services

To maintain continuity of care through the summer months, FMC staff continued to provide services at the schools that remained open during the summer. The primary variable for summer services was the availability of the school building, a factor that was often outside of FMC’s control. For some districts, FMC clinic sites and virtual services were available to continue services for students if the parent made the effort to ensure the child continued. In other areas, the district provided a safe location independent of the district so that students and FMC staff had a physical location for therapy services during summer shut down, breaks, and inclement weather days. They also offered to meet students at FMC offices near the schools, though this did not result in many appointments. Participation during the summer months decreased drastically, in part due to a lack of parental engagement and transportation. While some students were transported to the schools and offices by family members, and others received transportation services through their Medicaid insurance plans, others went without care. FMC continues to modify and adapt summer programming to meet the needs of students even when school is out of session.

Growing Services and Staff

Over the course of the three-year grant project, staff treated 381 students and conducted 3,103 appointments. 13%, or 300, of those appointments were telepsychiatry visits. FMC employed two medical support coordinators and five social workers to meet this need. Following the grant period, FMC expanded services and staffing to reach additional schools in both the rural and urban setting. To date, the team consists of nine socials workers and three medical support coordinators.

One of the biggest challenges FMC faced in project implementation was maintaining a sufficient level of staff. Two social workers and a medical support coordinator hired for the project left in the first few years of the program. Covering such a large geographic area required significant travel for staff, which contributed to “compassion fatigue”, burnout, and decreased job satisfaction. To address this, FMC increased salaries and began reimbursing for mileage for traveling between school sites. FMC also prioritized self-care and support for their social workers and medical support coordinators by having regular conversations about their needs and implementing benefits like flexible hours to support staff wellbeing.

Many of the school-based staff describe the strong relationships they have developed as one of the reasons for wanting to stay in the position. A common theme among the school-based staff is that they are passionate about the work they do and genuinely strive to make a difference in the lives of the children and families they work with. This is something important to look for when bringing on new team members to the program.

Lessons Learned

• Make specific plans for continued care during the summer months to overcome barriers related to parental and student engagement and transportation.
• Plan for a flexible and fluid appointment schedule during the school day. The medical support coordinator and the social worker often shifted appointment times to account for academic demands and students’ needs.
• Anticipate the unique stresses and associated needs with staff working on this program, such as regular daily travel, navigating a new model of care, and secondary trauma. In the program design, shape the position and benefits to mitigate these pressure points, and plan for interim assessments of staff roles, expectations, and satisfaction. Be prepared to adjust as needed.

• Tracked individual health progress: While this data wasn’t enough to be statistically significant during the grant period, FMC continues to gather and analyze health outcomes over a longer time.
• Focused on access to services: In a pilot, the most important questions might be about the program itself: Did it function as expected? What unexpected challenges came up? Did it provide access to more students? Is is sustainable? The answers to these questions can be found throughout this toolkit, and can substantially help FMC and others with the next steps.
• Evaluated management of behavioral health conditions: FMC might not yet have the full picture of its long-term impact on students, but they can see how their program helped students address behavioral health needs that otherwise might go untreated.
• Emphasized qualitative data: Feedback from students, families, school professionals, and program staff were key to understanding the program’s impact and how it can be improved.

By receiving federal approval to add each school as a service site, FMC was able to bill Medicaid for services delivered and receive an enhanced wraparound payment as an FQHC. They also ensured that all staff were credentialed with all of the Medicaid health plans in the counties of operation as well as commercial insurers. For the schools, partnering with an established healthcare provider eliminated the need for district staff to learn the details and requirements of insurance billing, making an FQHC a low-risk, high-reward partnership.

FMC used a sliding fee scale for families without insurance or with high deductibles and did not turn any student away due to an inability to pay. For students without health coverage, FMC staff assisted the family with signing up for affordable insurance.

With a sustainable and scalable funding model, FMC is maintaining and expanding services now that the grant period has ended. For example, FMC is:

• Continuing to provide services in all of these schools
• Increasing the number of days social workers are present at two school sites
• Expanding services to five schools in currently served districts and to five schools in two new districts, including three schools in Detroit Public Schools Community District. They are also looking to expand into schools in Wayne County and Toledo, Ohio.

Beyond FMC’s plans for expanding their program, the project serves as a proof of concept for other FQHCs and school partnerships. FMC demonstrated that a provider can successfully base behavioral health services, including tele-psychiatry, in schools, and that this model is effective for reaching students and eliminating barriers to care. The work is unequivocally replicable and adaptable for communities across not only Michigan, but the entire country.

Lessons Learned

• Ensure that all requirements to bill Medicaid and other insurers for services are addressed and that there is a clear understanding of billable services.

Here is a compiled list of resources that relate to the Michigan Health Endowment Fund Telehealth Implementation Case Study:

• FQHC and School MOU
• Job description for behavioral health medical support coordinator
• Flyer to parents about school-based program
• Program handout for parent-teacher conferences
• Presentation to school staff on behavioral health services
• Description of intervention implementation plan
• Presentation for parents on the screening and intervention
• Referral form for school-based behavioral health services
• Parental consent and registration form, completed with staff
• Parental consent form for controlled substances
• Depression Assessment: PHQ-9
• Anxiety Assessment: GAD-7