The Children's Aid Society

Testimony Before the New York City Council on School-Based Mental Health Services

March 22, 2007

Budget Hearings - Mental Health
Good afternoon, I am James Langford, Director of Quality Control and Improvement for The Children's Aid Society, (CAS), and am representing our Chief Executive Officer, C. Warren "Pete" Moses. CAS is one of New York City's oldest and largest child and family direct service providers, and we are pleased to offer testimony on issues related to the funding and delivery of mental health services to children in New York City. Community health and mental health services, both school based and community based, are key components of our service delivery and programs. Today, we want to draw your attention to the need for additional school-based mental health programs, and to suggest some cost effective strategies for funding. We have found that providing on-site support services in schools can:

1. Increase engagement, as children have better overall access to treatment.
2. Can improve student well-being and school climate.
3. Can reduce inappropriate referrals to Special Education.

Over the past 15 years, CAS has developed "full-service" community school models to augment children's learning opportunities and to reduce barriers to their school success. In partnership with the NYC Department of Education, we have continued to expand our Community Schools, and several outside evaluations, done by both Fordham University and the Acknowledge Center of CUNY,[i] have demonstrated the effectiveness of CAS's "full-service" community school's approach - which transforms the school into a center of community life by offering after school academic and recreational programming, health and mental health services, and parent engagement activities.

Our work in the area of school-based mental health services predated the opening of our first Community School in Washington Heights at I.S. 218 in 1992. Our On-Site mental health clinics at P.S. 208 in Central Harlem were started in 1984, when DOH&MH and DOE joined forces to create an expansion of On-Site School Based Mental Health Programs throughout the city. The On-site programs launched in1984 originally had 19 mental health providers based at 73 school sites, and all employed full time staff. Yet in 2005, 57% of the original schools were no longer a part of the On-Site School based mental health program, and only four programs still had full time staff.[ii] Overall, NYC has lost ground in its community mental infrastructure as well. A fragmented and complicated funding system, with insufficient reimbursement, has led to many other community mental health clinic closures in recent years.[iii]

Our agency has continued to compete for scarce funds, and in 2000, CAS was awarded a grant through the New York State Office of Mental Health's School Support III Project for two of our Community School sites in Washington Heights. This funding allows us to successfully operate two Article 31 licensed Mental Health Clinics that have been seamlessly integrated into our school-based medical clinics for over 6 years. However, the base funding under School Support III that has funded those mental health clinics will end in June 2007. The New York State Education Department has discontinued its share of support for these programs, despite the fact the NYS Regents has sought to promote the expansion of school-based mental health. We cannot sustain these clinics solely on fee-for-service Medicaid Reimbursement. In our constant effort to seek funds, we recently applied for New York State Office of Mental Health funding under the new Child and Family Clinic Plus initiative. We were successful in this endeavor, but revenue that is projected for this new program will only be slightly higher than the current fee-for-service rate, with no base funding for staff positions. Time will tell if the providers that have been selected to implement this new program in public schools will be able to meet and sustain the new capacity levels of service that will result from the mass screening that the program requires.

While we are pleased that NYS OMH recognizes that schools are an effective locus for mental health services delivery, the need for children's mental health services in New York City continues to be unmet, and ever growing numbers of students in our schools present with disruptive, threatening, aggressive, and suicidal behavior, which typical school staffing is ill-equipped to handle. We have found that in all of our community school settings, principals have consistently requested on-site mental health services. Yet most schools do not have such services, and faced with a shortage of resources, and coupled with pressure to raise test scores, schools have increasingly been calling 911, which results in taking children with behavioral disorders to hospital emergency rooms.[iv]

Tangentially, the NYC Department of Education commissioned a report on the status of special education in New York City. The Hehir report, released in 2005, had many constructive recommendations with respect to the reorganization and delivery of special education services, and called for more consistent pre-referral supports for students with challenging behaviors.[v] The report also found that in 2003-2004, the special education budget in New York City was $3.4 billion dollars - approximately 25% of the overall school budget in our city that year. Compared to Chicago and Los Angeles, where special education comprised 14.9% and 9.6%, respectively, of overall school budgets in that same year, our spending on special education consumes a much larger share of our overall education budget. A portion of our spending on special education should go to pre-referral supports and the mandated reinstatement of effective Pupil Personnel Teams.
Unmet and Growing Needs In the Bronx

In a recent survey conducted by the New York City Department of Health and Mental Hygiene in the Bronx, there were 6,546 actively enrolled children in twenty-one licensed outpatient mental health clinics - 18% were in the foster care system. The survey also found that 57% of the children enrolled in treatment had an average wait from the time of referral of about six weeks – an unacceptably long period of time for a child in crisis. In addition, the survey found an attrition rate of 57% of referred children to treatment, meaning that for every 100 referrals for outpatient mental health services, 43, or less than half, received any treatment.[vi]

This trend points out the need to develop more services where children interact with peers and concerned adults every day – in our public schools. With few school-based mental health clinics in the Bronx, most high need schools have had to rely on the limited capacity of "crisis intervention" teams to cover emergency interventions. This lack of services is one reason why school administrators have often used the phone call to 911 – and hence the hospital emergency room system, to deal with perceived student mental health issues.

What Is Needed: A More Cost Effective Alternative
We need a new strategy with a more cost effective approach needed to tackle these growing needs, and to sort out the maze of current NYS regulations and fiscal barriers that have had a negative impact on the expansion and sustainability of community mental health clinics. New ways to enhance reimbursement must be explored, so that New York State's current "Medicaid cap" or Medicaid Neutrality policy, can be amended - and more school-based Article 31 licensed clinics can be established. In tandem, the NYC Department of Education must identify available funding that can be added to billable Medicaid services, or that could be shifted to provide an increased local/state match for Medicaid.

We also support the recent campaign of the Coalition of Behavioral Health Agencies, which is calling for New York State to carry out a complete restructuring of reimbursement for Article 31 Mental Health Clinics – a new system is needed that is based on the actual cost of delivery of services, and that would incentivize performance outcomes.
To address the growing unmet need described above, the development of new school-based student support models are needed. Specifically, these school-based interventions would:

• Demonstrate the ability of public schools, in partnership with private organizations, to deliver effective school-based mental health and family support services that will include triage assessments and immediate support in a crisis, thereby reducing inappropriate use of hospital emergency rooms for evaluation of "low risk" children. Inappropriate special education referrals will also be fully assessed before they result in placement.
• Create a new model of effective collaboration between public school teachers and private mental health/social service providers. A comprehensive training and staff development program for existing school-based student support teams and school faculty would accompany this. Pupil Personnel Teams that can carefully assess student needs and behavioral issues are an effective component of the model.
• Create a new financing model that will assess what DOE funding may be used to create replicable new on-site services that benefit all students, and that will augment the special education system, offering other alternatives for assessment and intervention. Non-reimbursable mental health counseling must also be funded. Where possible, local and state public funding should be redirected to provide an increased match for Medicaid funds. The Campaign for Fiscal Equity could be another source of new funding in New York City.

The purpose of creating a cost effective school-based mental health program model, and of developing a new financing strategy, is not only to help more children who are suffering with emotional problems, but to also enable more children to remain in general education settings, while helping to guide the system into a more cost-effective direction. A substantial body of research under girds the approach we are recommending,[vii] as does an innovative and successful experiment taking place in Boston.[viii]
Reducing Special Education Referrals and Increasing School Attendance

Over the past 10 years, CAS community schools have demonstrated that a common philosophical, professional and procedural framework can help schools move beyond the current trend - sometimes described as an "emergency room" approach, in which school staff regularly refer disruptive students who need help with behavior management but are not in need of mental health services. Additional training and non-clinical supports must be offered to teachers who need help in managing students with behavioral problems, while they are concurrently trained to recognize the signs of those children who are truly suffering with mental health problems. School-based after-school program staff that are part of the new DYCD OST programs need such training as well.
A comprehensive Community School approach, with adequate on-site health and mental health services, can significantly reduce referrals to the special education system and can increase overall school attendance. School report card data from the five CAS Community Schools where CAS has had its longest presence has shown both higher attendance rates – as compared to citywide averages at similar schools, and lower referral rates to special education. Over a 5-year period (2001- 2005), based on data from the NYC school report cards, attendance rates at the five CAS Community schools shown below were 1.7 percentiles higher than at comparable city schools (92.6% attendance vs. 90.9%), and over the same 5-year period, rates of initial referral to special education were 20% lower at CAS schools than at comparable schools (3.0% vs. 3.7%):

*In the 2004 -2005 school year, IS 218 and IS 90 were made in to several smaller middle schools within the same buildings. The average calculated for the new Mirabal Campus Schools (IS 90, MS 319, MS 321, MS 324) has been totaled and is included in the 5 year average shown on the IS 90 line. The two other new middle schools at IS 218 – (322, and 293), had no data available as of the time of this report.

If more New York City schools can adapt existing models of student and family support services, special education referral rates can be reduced in greater numbers throughout our system - saving substantial amounts of money. These cost savings can be used to help finance the sustainability of school-based mental health programs. Concurrently, The New York State Office of Mental Health and the New York City Department of Health and Mental Hygiene must address the insufficient reimbursement of services by matching Medicaid dollars with alternative sources of funding, in partnership with the New York City Department of Education, to develop and sustain services and interventions, and to insure that space is available for these services in high-need schools. Thank You.

Endnotes
[i] See attached Summary of CAS Community Schools Results to Date, January 2006.
[ii] Preserving School-Based Mental Health Programs: Critical Resources In Promoting Educational Achievement In New York City Public Schools, by the On-Site School Based Mental Health Steering Committee, Final Draft, October 2005.
[iii] New York Nonprofit Press, "Clinics In Crisis-Funding Squeeze Threatens Closure," February 2005, Volume 4, Issue 2. page 10.
[iv] From the United Way of New York City, The Bronx Collaborative for Children and Schools, page 8, where the results of a survey of 5 out or 8 hospital emergency rooms in the Bronx were surveyed in May 2004, and which estimated that 2,802 children are sent each year by schools to be evaluated by these ERs. This school-based mental health initiative surveyed in Bronx DOE Region 1, and found that in 5 out of 8 Bronx Hospital Emergency Rooms, a total of 6,835 children are sent each year to be evaluated – and of these, 41% or 2,802, originate from schools. Furthermore, 55%, or 1,051, were deemed by ER clinicians to be at "low risk." This inappropriate use of the ER costs about $1,000 per visit. The majority of these referrals are boys - demonstrating disruptive behavior. Needless to say, such a trend also has a traumatic affect on the child, rarely results in getting services that are helpful for the child and family, and is costing an exorbitant amount of money – up to $1.5 million a year.
[v] See, Comprehensive Management Review and Evaluation of Special Education, submitted by Thomas Hehir and associates, to the New York City Department of Education, September 20, 2005, page 92.
[vi] Children's Mental Health Needs Assessment, New York City Department of Health and Mental Hygiene in Collaboration with the Mailman School of Public Health at Columbia University, August, 2003.
[vii] See, for example, Making the Difference: Research and Practice in Community Schools, a 2003 report prepared and published by the Coalition for Community Schools. This research synthesis documented five conditions for learning that are fully consistent with the proposed approach. These conditions include: (1) The school has a core instructional program with qualified teachers, a challenging curriculum, and high standards and expectations for all students; (2) Students are motivated and engaged in learning, both in school and in community settings, during and after school; (3) The basic physical, mental and emotional health needs of young people and their families are recognized and addressed; (4) There is mutual respect and effective collaboration among parents, families and school staff; and (5) Community engagement, together with school efforts, promote a school climate that is safe, supportive and respectful and connects students to a broader learning community.
[viii] Alliance for Inclusion and Prevention, Program Summary, 2003.