Issues and Opportunities in the Organization and Financing of Mental Health Services in School Julia Graham Lear, Center for Health and Health Care in Schools, SPHHS, The George Washington University Medical Center Board on Children, Youth,and Families, National Academy of Sciences, May 20, 2004

Mental health services in schools: an overview The school setting Basic questions in school-based mental health services Current approaches to service delivery Organization-of-care issues Financing challenges

The School Setting School system structure -- locally & state driven & funded, with federal government paying about10% of total cost of elementary/secondary schooling. States & localities, and private sources provide 48%, 42%, and 9% respectively. Unlike health care, local communities may take active role in deciding what programs and services are allowed in schools (Community elects school board, votes on special funding referenda)

Opportunities in a School Setting A school “base” enables providers to overcome access barriers for most children. 52 million American children and youth between ages 5 and 17 attend school; 90% attend public schools. Perversely, economic and racial segregation in schools enables targeting on those populations with greatest need. Many school districts, especially the largest, have established mental health-service arrangements -- including school system-organized care, school-based extensions of community-based mental health programs, & school-based health centers.

Basic questions in school-based mental health services Population-targeted practice v. individual-targeted practice? What services to be offered? Prevention? Screening? Diagnosis? Short-term interventions? Long-term services? Whose goals? Is mental health care in schools supporting an education agenda or a health agenda?

Current approaches to school-based service delivery School -system organized care School-based health centers: primary care & mental health School-based mental health services

Organization-of-care issues Who’s in charge? Clinical practices: methods, quality measurement, confidentiality, parent consent Staffing: credential and training requirements, continuing education, union issues

Financing challenges Multiple sources of funding: state grant funds; Medicaid; managed care -- carve outs, carve-ins, falling in-between; local health and education budgets Meeting requirements of funding agencies Ability of provider organization to bill and collect from 3rd party payers