Transcript: Schools as Centers of Wellness: A Collaborative Approach to School Mental Health
On behalf of the California Center for School Climate (CCSC), I’d love to welcome you today to Schools as Centers of Wellness: A Collaborative Approach to School Mental Health. My name is Jenny Betz. I’m a Senior Program Associate with WestEd and a Technical Assistance Provider for the California Center for School Climate. I’m going to be your moderator today as well, which is just a little bit in the beginning, and then I’ll help moderate the Q&A at the end.
The California Center for School Climate, or CCSC for short, is a California Department of Ed initiative led by WestEd. We provide free support and trainings on school climate and data use to local LEAs throughout California. We invite you to visit, if you haven’t already, our website at ccsc.wested.org to explore all the different supports that are provided to districts and schools across the state. We offer several types of support, including data use webinar sessions, peer learning exchanges around specific topics, professional learning supports, including webinars, events like this, and also more ongoing professional learning courses. And our website can be found again on that Linktree that was shared in the chat and you can go to that anytime and you can always email us. Lots and lots of good stuff for you all through the center.
In the keynote this morning, if you all were there, Jaleel Howard noted really the importance of meaningful connections between students and adults in school. He also shared examples of how to develop better relationships with young people and talked a lot about listening and self-reflection for adults. And I think that really connects in a lot of ways to what this session is. During this session we’re going to continue to talk about the power of relationships while really focusing on how schools can be centers of wellness for students and for members of the school community. Our speakers are going to be sharing some of the amazing work that they’ve been doing in Sacramento County to support their local districts and schools.
And again, a reminder, the Zoom chat will remain open for the session and we invite you to interact with other audience members there. We’ll also have time again for the Q&As towards the end of the session. And if you have questions that you want answered there, feel free to put it in the Q&A. Use the Q&A button here on your Zoom toolbar. And the session slides and resources, anything that we mentioned throughout will be in the Linktree, and then the recording will be shared later on our website.
We have a really great lineup for you today. I’d like to introduce our guest speakers for this session from the Sacramento County Office of Education (SCOE). We have the lovely Christopher Williams, Director of School-Based Mental Health and Wellness and the awesome Marcella Rodriguez, Coordinator for School-Based Mental Health Services. They’re both fantastic and their work is fantastic, so you’re really in for a treat. With that, I’m going to stop sharing and pass it on over to Chris.
Thanks, Jenny. Good morning, everybody. As Jenny mentioned, my name is Chris Williams and I’m the Director of School-Based Mental Health and Wellness at the Sacramento County Office of Education. I am not a native Californian. I’ve been told that that’s obvious. And when it was told to me, I don’t think it was intended as a compliment. I am from the East coast originally, from the Northeast. I cut my professional teeth in New York City where I was a school social worker. Worked in a couple of different high schools up in the Bronx. I helped to create a design and mentoring program, specifically an intervention for chronic absenteeism. And that got me invited to the mayor’s roundtable. Mayor Bloomberg was the mayor at the time. We helped to design a mentoring program for the whole city. From there, I helped to found a nonprofit which provided mental health services in schools.
During that time, I met my wife who is a native Californian. She’s from Chico. And at one point in time, she told me that she was heading back to California and that I was welcome to join her. We took a quick detour up to Boston, where I did my doctoral studies and then came out here. And I’ve been in Sacramento for about the past five years, working at Sacramento County Office of Ed for four years. And I love many things about my job, one of which is I get to work with Marcella. And so Marcella is going to introduce herself.
Good morning, everyone. It’s great to be in space together. I am a native Californian. Was born in San Diego. My mom is one of 17. And when I was about 12, family decided to move on up to Sacramento. And so there we went. I went to a local junior high school, a local high school nearby. Stuck around for my college experience here. And have certainly enjoyed serving the community that’s helped develop and make me who I am.
I’m first generation latina-americana and certainly love serving our community. And folks may not know me, but I’ve lost my voice. I’m gaining it back. And so, I’ll take a couple slides, but really saving my voice for the question and answer component of this presentation. Pass it back over to you, Chris.
Great, thanks Marcella. Our role today is to share with you a little bit about our work here in Sacramento County, where we are aiming to transform schools into centers of wellness. And we’re doing that by partnership with the Department of Health Services.
And through that partnership, we are bringing licensed clinicians into schools, the vision of which is to place a licensed mental health clinician in every single school in Sacramento County. We started about two years ago. And we’re going to give you an overview of that program today. Our goal is to talk for about 25 minutes or so.
As Marcella said, I’ll take the bulk of it to save her voice. She will share some slides towards the end and then we’ll open it up for questions. Hopefully, we’ll have a good 20 minutes or so for questions at the end. And so with that, I’m going to go ahead and share my screen.
Okay. Marcella, can you give me a thumbs up? Is that working? Awesome. And it is a little awkward. As I mentioned, I’m a former clinician myself, so I very much enjoy interacting with folks. And in this kind of webinar format, I’m just talking to myself, which is a pastime of mine. I’m not going to lie, but it’s a little awkward for me to just be talking to myself at this blank screen. But just want to name that and we’re going to do our best as we move forward sharing our program.
Again, Sacramento County School-based Mental Health and Wellness team where we are working to transform schools into centers of wellness. We already introduced ourselves and we’re moving right along. This is our objectives are really, these are the tenants more than anything else of our program. I challenge you, as we move forward, to listen and see if there’s anything that we say that can’t be connected in some way back to one of these objectives.
We believe that everything that we do is connected to one, if not all of these tenants of our program. Everything starts with the relationships, whether that’s the work with the students, with the teachers or faculty, the principals or admin, our district partners, our county partners, our partners that manage care organizations and our partners at the state, everything is about relationships.
Because of that, it’s a collective impact model. I heard somebody say that if you want to go fast, go alone. If you want to go far, go together. We want to go far. We are really working on building trust, engaging folks who are already doing this work and working to collectively to move this initiative forward, transforming schools into centers of wellness.
To do that, we have to integrate systems, namely the health system and the education system. But then how are we building sustainable systems at the school sites in the districts and the communities that we serve all through the aim of improving access to care? At the end of the day, the penetration rate in California is about 4% students who have access to mental health services, who actually access mental health services. Access to care has been named as a huge obstacle. Bringing services right into schools is improving access to care through those other objectives.
This is a quote. And I’ll just pause and let you all read that quote. (On screen: “I would like to beg you, dear Sir, as well as I can, to have patience with everything unresolved in your heart and to try to love the questions themselves as if they were locked rooms or books written in a very foreign language. Don’t search for the answers, which could not be given to you now, because you would not be able to live them. And the point is, to live everything. Live the questions now. Perhaps then, someday far in the future, you will gradually, without even noticing it, live your way into the answer.” -Ranier Maria Rilke) And I’ll invite you, even though I can’t see anybody, go ahead and put some thoughts into the chat. What’s resonating with you about this quote? Why would we start with this quote?
Do well to be curious, patient, live the moment and solutions will come. Curiosity, important to be self-reflective. To look at ourselves in the mirror first to help others. Hard to be in the moment. Trust the process. Mindfulness, stay in the moment. Honor the journey. Yeah, I love all these reflections and thank you all for engaging in this with us. Even this chat format is not perfect.
This is a quote that we open just about every meeting with. I think our team now can probably recite this quote. But it’s really important for us to continue to put this in front of ourselves and look at it. Because what we’re doing, we’re bringing the health systems and the education systems together to improve access to care for students and families, some of the most traditionally underserved or marginalized families.
And while the way that we’re doing it, we’ll get into this in a moment, is by extending the county federally qualified health system or health center status to schools, this exactly what we’re doing hasn’t been done before. And so therefore, we have to really understand that there’s a lot of things that we don’t know that we don’t know.
And to understand what we don’t know, we have to continuously ask the questions. The scientific model is about asking questions which then lead to better questions. We’re never proving anything, we’re just continuing to interrogate and find better ways to ask questions, better ways to inquire what could be, what’s possible.
And for us to dive into what’s possible, that is I think how we’re going to be successful. It’s not about us in a room somewhere, thinking how smart we are, designing something and then going and plopping it into schools because we don’t understand every school. Particularly in Sacramento County, schools in River Delta are very different from the schools in Sacramento Unified, which are very different from Folsom.
Every school context is slightly different. And so, we really have to seek to understand before we can really help to solve anything. And so, this quote is not up here just as an icebreaker. It’s really a core component of our program where we’re trusting the process, seeking to understand and really living the questions together collectively so that we can collectively improve.
One more analogy before we dive in. Everybody has heard that analogy of we’re building the plane as we fly it. Well, that’s super scary. I don’t want to do that. I don’t know anybody who wants to do that. Who would want to do that? What we think of is we’re trying to build a sandbox as we’re playing in it together. And we think that that’s going to be welcoming and inviting. And that we have to have a sense of play and a sense of curiosity, a sense of adventure for this, rather than something super scary like flying a plane as we’re building it.
These two slides are present with us in all of our team meetings with our principals or the district partners, our internal meetings. So that we can continue to remind ourselves that we’re asking really good questions, or hopefully we’re asking really good questions. And that we have to play together while we’re also discovering.
What are we doing? Well, first and foremost, I think we have to ask why. Why is it important to bring mental health services into schools and transform schools, interest centers of wellness? We’re going to share some stats with you, probably not terribly unfamiliar to anybody and some of our underlying principles.
And first of all, there’s really great work happening in Sacramento County. There is pockets of really good work serving students and families. And much of that work is not cohesive or integrated. We are really seeking to find those pockets of really good work and then build a system that is integrating this into a coherent, cohesive model while also developing new systems.
And this is one of the driving tenets of our work. This is taken from an article that Dr. Jack Shonkoff wrote, who’s the director of the Center for the Developing Child back in 2012. Is that, “Development is driven by an ongoing inextricable interaction between biology and ecology.”
Well, thanks, Dr. Jack. But what does that mean? What it means essentially is that that age-old question of nature versus nurture really isn’t a question. It’s not either, or. It’s both. And then we’re also born with certain predispositions. And then it’s the experiences that we have that turn on or turn off those predispositions and shape our development.
And a lot of this work has been born out of the work on childhood stress and adverse childhood experiences, that negative experiences deleteriously affect development. And this is leading to a whole new field of study in neuroscience called epigenetics. And so, if negative experiences, adverse experiences, stress, toxic stress impact us, our development physiologically, well, couldn’t the reverse also be true, that positive experiences can help shape healthy development?
And so when we think about schools as centers of wellness, schools are a source that can shape development in a healthy, positive way if we focus on the experiences that we are co-creating with the young people we serve. Adults, every adult has a responsibility to attend to the healthy development of the kids they serve academically sure, but also socially, emotionally, psychologically, physically.
And if we can all come together around this, then we can all understand our role and all help to shape that development. And we all know why we need to do this. One in five students has a diagnosable mental health disorder, 80% of whom don’t get treatment. 50% of those students wind up dropping out of school, which then just exacerbates further challenges and system involved youth.
And then of course, that last quote or last line, which is devastating, is that suicide is now the second leading cause of death among teenagers in our United States of America. All of these statistics are pre-COVID. And to nobody’s surprised, COVID didn’t make any of this better. These are again, pre-COVID numbers just emphasizing the dire state of mental health for young people in our country. California there ranks 43rd in the nation in providing behavioral, social, developmental screenings. And we’re also in the bottom third for drawing down Medi-Cal dollars to support interventions around health and mental health.
Like I said, COVID made any of this any better. It’s exacerbated sense of isolation. This whole conference is about relationships and relationships as a healing mechanism. Well, if you’re isolated from one another, we don’t have the opportunity to be in relationship with one another. COVID has made this a lot worse.
And finally, and last, but certainly not least, the consequences are way worse for students who don’t look like I do. We live in a country that has exacerbated and developed systems of oppression and marginalization. Those systems make all of these stats way worse for students who don’t look like I do. When we’re thinking about transforming schools and centers of wellness, we can’t just nibble at the edges of equity. Equity has to be at the center of our design principles. And understanding how are we looking at everything through an equity lens and how are we rooting out racist infrastructures of the systems within which we operate.
I didn’t come here to bum anybody out. These stats are all terrible, but the good news is that in that same article of 10 years ago, Dr. Shonkoff gave us a prescription. And he says that the essential characteristic for mitigating toxic stress is the presence of protective adult relationships. Notice he doesn’t say protective parental relationships. He doesn’t say protective relationships with folks who have initials after their names. Protective adult relationships.
Any adult who develops a caring relationship with a child is a mitigating factor for stress. Because toxic stress by definition is the prolonged activation of the stress response. When a young person is in the presence of a caring adult, they can come down out of that stress response because they feel trusted, they feel seen, they feel valued. And that stress response dissipates if only for 50 minutes.
But by definition then, that activation of the stress response is no longer prolonged. Stress then can remain manageable. Protective adult relationships are a mental health intervention. And I ask you, who is better positioned to develop protective adult relationships with children than the adults with whom children spend the majority of their time? Schools must be an essential actor in our response to the mental health crisis.
And that’s what we’re doing. We are building a scalable, coherent integrated system in Sacramento County, bringing licensed mental health clinicians into schools, establishing a beachhead. And then allowing for a conversation with everyone in the building to understand their role in supporting the healthy development of the kids they serve. I want to talk specifically about what we’re doing now.
Again, this is a collective impact model. We have multiple partners at the table. On paper, our partnership, our contract is between SCOE and Department of Health Services. Now through SBHIP, we’re developing MOUs with our managed care organizations. We also have MOUs with our districts and schools. But of course, we have to engage all of the partners, the community-based organizations, the families themselves, the students.
Four times a year we host a student mental health and wellness collaborative where multiple stakeholders can come together and talk about what’s impacting them and how are we then being responsive in the development of our program. Our vision of this program is to bring the education health systems together to create a continuum of care for mental health and wellness. Again, every adult has a role to play.
The mission, along with our schools in all 13 of our districts, is to identify and address the mental health needs of all students in Sacramento County. Just remember that we’re going to come back to that a little bit later. Identify and address. I think a lot of folks want to jump to address, but how are we identifying students in need of support? I should have muted my phone.
The goals of this program are, as you can see, both behavioral, behavioral health, mental health and education related. We are working with some partners at UC, Berkeley to develop a research practice partnership where they’re evaluating our program. And we’re hoping to see at the student or school level decreased chronic absenteeism, decreased behavior referrals, increased graduation rates. But in the long term, really what we hope to do is to understand what leads to early adult or adolescent onset of anxiety, depression, suicidality. And enter preventative measures into elementary, middle schools so that we over time see a reduction in anxiety, depression, suicidality, and other mental health disorders through those preventative measures.
Our funding, this is one of the innovative aspects of our program, is that we’re extending the status of the county-run Federally Qualified Health Center, or FQHC. That’s the Sacramento County Health Center. It’s part of the Department of Health. It’s the primary care division of Department of Health Services, that FQHC status, we go through the federal government. We apply. They name our schools as satellite centers of the county, FQHC, which then allows us to place licensed mental health clinicians into the schools, provide direct mental health services. Assessment, diagnosis, treatment.
We log everything in the electronic health record system of the county. That triggers the billing mechanism. And then we get reimbursed at the FQHC rate, which is called the PPS or Perspective Payment System. That’s a little in the weeds. But essentially, it’s a revenue generating model. We’re providing services, it’s like a fee for service for Medi-Cal. We provide a service, the FQHC rate is pre-negotiated and we get paid. We, SCOE, hire the clinicians when we operate under the contract with the county.
This is a sustainable model. The goal is to make this free for the schools, free for the districts, free for the students and families. We are using some of the one-time dollars, the MHSSA grant and the SBHIP dollars to start this and fund the expansion. But essentially, this is a self-sustaining model that can go on in perpetuity.
The essential components I mentioned already. We, SCOE, hire the clinicians. They provide the direct mental health services. In our MOU with the schools and the districts, we also name that every school has to have an approach to tier one. Namely SEL, social-emotional learning. Marcella is going to talk a little bit about our tier two interventions that we’re developing.
We also have partnerships with First 5 and other early learning organizations to reach back into those early learning years and help support families again with these preventative measures. And again, this is all Medi-Cal. We started two years ago. We were in 10 schools. We are now in year three, we’re in cohort three. We’re under contract with 40 schools, 11 of our 13 districts and one charter network. And through our SBHIP dollars, we have a clear pathway to get to 80 schools within the next two years. Again, the vision of this being to be in every school in the county at some point. And that’s a little over 300 schools.
One more essential component that we want to mention. We’ve all seen a version of this pyramid before, the MTSS model. And typically, or traditionally I should say, when there’s a licensed mental health clinician in a school, a referral might go from one individual to another individual. Until a teacher sees something happening, the teacher refers to the clinician. It’s a one-to-one interaction.
And what we want to do is develop systems so these are not people dependent. And one of our systems is to develop coordination of services (COST) teams on every campus. Our COST, we didn’t make this up, this is a thing that exists in the world. Our COST is a team that sits outside MTSS.
Referrals come into COST. And then COST works as a navigation system for MTSS interventions, inclusive of clinical interventions, but not only clinical interventions. What’s happening in the afterschool or expanded learning space, other lunchtime clubs? Who else can work on engagement methods to support students? And then we also have to have a universal referral system in place that all referrals come into COST. And then we navigate to the rest of the MTSS.
We’ve enjoyed a few successes. We’ve made tons of mistakes. We’ve enjoyed a few successes. One is proof of concept. We are billing Medi-Cal, we’re getting paid. And that we now have a clear pathway to sustainability. We have a partnership with Yale and their Center for Emotional Intelligence. And their approach to SEL, which is called RULER. We’re developing other pathways for SEL interventions in schools as well.
Coordination and services team, I just mentioned. Collaboration, I’ve been talking about this whole time. But we have great partners all throughout Sacramento County and we are engaging in clinical services. To date, we’ve served over 600 students and we now have close to 400 students across our county who are getting ongoing mental health supports through our clinicians. We have 33 clinicians in schools right now, serving close to 400 students on an ongoing basis.
Lastly, before I turn it over to Marcella, is this is a program, as we mentioned in the questions. We are responding to what’s happening in real time. And what we’ve noticed is that there are still issues of/or concerns around trust, concerns around engagement with the community, with the family members.
And so we are launching a new position in just a couple weeks. Pretty exciting, a family and community health system navigator. These navigators will be of and for the community. It’ll be primarily a liaison between the schools, the health systems and other youth or family serving agencies.
Primary responsibility will be to build community engagement, which means building trust. And sometimes in some cases, maybe restoring trust with communities. Improving mental health awareness and reducing stigma. And then insisting with the enrollment to Medi-Cal and registration within the electronic health records system.
This is also going to be connected to sustainable dollars. Last summer, DHCS authorized community health workers as an eligible Medi-Cal provider. And things like Parent Partners have already existed. This is everything is connecting to sustainable dollars.
And lastly, as I mentioned, we have these SEL relationships to tier one, the clinical interventions at tier three. There is a gap that we’ve noticed in tier two, and Marcella is going to talk about what we’re doing to address that gap through our career pipeline. Marcella.
Thanks, Chris. In our exploration of living the questions, what we knew, what we found was that there’s certainly a workforce shortage. And so, we’ll go over our career pipeline. Chris, if you want to head to the next slide.
As Chris mentioned at the beginning, all of what we do is in partnership with members of our communities. And so, we knew that in order to fully develop our career pipeline and to support the workforce shortage that we had to continue to build this in partnership. And so, our five main partners are noted here.
Our students, our families, our communities, our districts and schools who we serve. Our currently five Sacramento County Medi-Cal plans. And of course, the county Department of Health Services. Truly a collective impact model seeking to develop career pipeline to support the workforce shortage, dreaming of what can be rather than what has been. We’ll continue on to the next slide.
What we found, excuse me, we conducted empathy interviews to really dig into the needs. How do we develop a career pipeline to address the needs, not only of our students and families who we serve, but our team members who we serve, our interns? What we found is that we need to develop a diverse workforce, a diverse representation, culturally competent care, including multilingual services.
We know that at it can cause barriers. Access to care. Mayor, clinicians, our peer specialists, our graduate clinical interns, our family community systems navigators have the ability to speak the language and there’s representative of the community we serve. We know there’s a shortage of mental health professionals and we know that we must intervene early. Go to the next slide.
And so, we developed a career pipeline vision. And this too came from identifying what are the needs, through empathy interviews, as well as collectively cross-departmental programs coming together to say what is the vision. Develop a pipeline of skilled, motivated, and committed professionals that are diverse and representative of the students we serve and are prepared to serve in mental health, health, social, emotional, and overall wellness and education careers in our schools. There are three paths within the career pipeline and school-based mental health at SCOE and School-based Mental Health and Wellness is one of the paths.
As you can see here, these are the roles that were developed to address the workforce shortage (Graduate Clinical Interns, Peer Specialist/Mentor, Associate Clinician, High School/Peer Mentor and Student Leader), to address what was found in empathy interviews that may cause barriers from folks entering the field of mental health or accessing care. And so, your specialist mentor position, that’s an undergraduate role. Maybe someone who’s getting their AA or their Bachelor and is interested in the field of mental health.
A graduate clinical intern. That’s the graduate level. Maybe somebody going to school getting their MSW or their MFT track degree. We also developed an associate clinician position. And all three positions are rolling out or have rolled out this school year. And lastly, under construction, as you can see, there is a high school peer mentor or student-led role. We know that peer to peer support is quite impactful. And so certainly looking forward to continuing to develop that role. In time, all positions will be paid.
Continuing here, this too came from our empathy interviews. So, I mentioned the paid or stipend internship placement. We knew that our profession of mental health requires quite some hours of internship and, oftentimes, are unpaid and not all members of our communities can sacrifice an unpaid internship experience or time, and certainly, this was important to the work.
An 80-hour peer specialist training with a peer specialist certification rolling out or have rolled out. We knew that helping our folks engage in a peer specialist training was crucial. Mentorship through task and field supervision, opportunities to provide feedback. What’s working, what’s not? We want to meet the needs of the members who we serve and our interns as well. And pipeline opportunities and resources. This is for the college and career counseling component, resume building and review skills.
Pipeline planning. January 2023 was our first cohort of interns and so, we’ve welcomed folks. We’ll be expanding the pipeline program each school year, which we’re very excited about developing a high school component. I mentioned it was under development and we’re looking forward to rolling that out summer of 2023, so quite soon.
We’ll be welcoming our associates, I’d say, in the next couple of weeks, but who knows? The position will be closing soon, I believe. It’s this week or so, but certainly looking forward to welcoming our associates to an ever-growing community here and as a part of the pipeline.
That’s again a quick overview of our program, but also of the career pipeline and, just as a reminder, that right side, the sustainability model, we’re connecting everything that we do to a sustainable funding model. The state has been very responsive. I think, was it Gertrude who said, “Be bold and mighty forces will come to your aid”?
We launched this program right as the pandemic was hitting and CalAIM or California Advancing Innovations in Medi-Cal hadn’t been released yet. We took a risk, but since then, the response, not in response to what we’re doing, but just in response to the epidemic, the state is responding towards classifying a whole bunch of things, like peer specialists, community health workers, behavioral health coaches and now, there are ways and pathways to connect a lot of different school-based mental health models to sustainable dollars. Then, we also mentioned on the left there that we are utilizing some of the one-time funds that are being rolled out to help fund our expansion, but understanding that once these one-time dollars go away, we will have connections to these sustainable dollars and the program will go on in perpetuity really is our expectation.
And that’s all we got for you. Well, that’s an overview, a couple of the key components, and now we’re happy to take questions around what we presented.
Wow, thank you both so much! Goodness gracious. We also have a lot of really awesome questions that are coming in through the Q&A button down there from folks. There are some things that are just really technical questions that I think we can help you answer another time, but some of the big ones that are coming up, one of them in particular, and I think it makes so much sense because so many of our schools right now are doing things around community schools in California. Some folks are wondering how does this map with community schools? Is there a connection there?
Yeah, 100% there’s a connection. I think one of the ways that we’re thinking about it here in the county office is to, again, use the existing frameworks that are in place and then use the community school dollars to… I think there’s a gardener now outside my window. Perfect timing.
It’s right. You’re fine.
Use the community school dollars to enhance or bring in resources, but then connect them to the sustainable dollars. We think that the COST model, the coordination and services team, as a way to map to MTSS is a great way to think about this. Your community school director should absolutely be on your coordination of services team and we suggest that the principal be on the coordination of services team as well.
And then, the clinician, the school counselor, teachers, and whoever the kid-magnet in the school is — there’s usually several school kid-magnets. Think about the secretary from Ferris Bueller’s Day Off, the person who knows everything about everybody. And this coordination of services team could be something that is initiated through the community school dollars to bring those partners together to say what are the different services that are happening on the school campus or could happen on the school campus? And then that coordination of services team could be the vehicle to connecting students and families to those resources. Again, thinking of the school as the community center or the school as the center of wellness.
And then we think that connecting those services to the sustainable dollars is great. The community school dollars is fantastic. It’s a great opportunity and how are we thinking about these sustainable dollars once they go away and the state has been very… just fantastic, I think in creating that bridge, whether it’s SBHIP or the MHSSA grant or community schools, these are great things to initiate things, but how are we thinking about those sustainable dollars moving forward?
Great. Marcella, it looked like you were going to add to that.
I was just reinforcing that one person can’t do it all. One system can’t do it all. And so, the COST model that Chris refers to is truly working together in partnership to see this larger vision of really supporting our children, youth, and families to the best of our abilities, helping to meet the mental health needs of all.
Yeah, and that it’s not just about what I’m hearing — the county partnering with the school and what it… right? — but each of the pieces are also doing that work. It’s the COST process is so important to that. If it were just the county telling a school or a district to do a certain thing or we could support you in this way, but the school or district wasn’t doing their work in partnerships and listening and all of the collaborative things, it like doesn’t work. Everyone connected has to be doing that work.
That’s right. Yeah.
We also have been getting quite a few questions about some of the technical things around billing and licensing, which is always what folks have questions about. The first ones coming in are really from Tawny and Catherine asking about whether or not you can bill for things depending on whether the provider is licensed or not and what type of license. And then, also, how does funding work to get services to students who are not Medi-Cal eligible?
It should be, or it is, a whole separate workshop around Medi-Cal funding. Essentially, just to break it down as simply as possible, there are, I think it’s seven possible pathways to billing federal Medi-Cal dollars. You can go through the behavioral health, like EPSTT and the mental health plan. LEAs can bill directly through BOP or SMA. SMA isn’t really a billing. It’s like the random moment in time. County mental health has that, and then so on and so forth.
Hospitals can bill. We’re going through the FQHC model. And that’s a little different than most places. And SBHIP is meant to incentivize billing through managed care organizations or potentially through behavioral health services. Those are two different pathways. We are trying to explore as many of those as possible. What’s happening in a little less than a year from now is the state is enrolling their fee schedule for school-based services.
There’s still a little confusion around that as to whether that’s going to go through LEA or that’s going to bill directly through MCOs and, sorry, LEA’s: local education agencies, and MCOs: managed care organizations. In our model, we’re trying to explore as many pathways as possible. Our licensed clinicians are billing through the FQHC model. That’s the county Department of Health Services, federally qualified health system. That’s a separate model through which to bill.
We also have to develop a pathway for the community health workers, which would be the family navigators. With that, we expect to create contracts directly with the managed care organizations and bill directly through those managed care organizations. The peer specialists are likely going to have to bill through SP803, which is behavioral health. That’ll be a separate contact with behavioral health to bill through there.
It really is about braiding all of these funding streams. And we also, all of our clinicians and most of the folks in our department, are also signed up for SMA. And we fill out those random moment in time surveys to bill for that. Now we have to be careful for accounting for time. We are tracking all of that. But so that’s four different funding streams that we’re exploring here in Sacramento County for just this one program, and we’re exploring all of that.
Three years ago, I wouldn’t have understood a word that I just said. I didn’t know anything about Medi-Cal billing three years ago and I’ve learned all of it just through what we’re doing and with our partners. And our clinicians do not need a PPS. They’re just licensed through the board of Behavioral Sciences, but they have to be supervised here at SCOE by somebody with a PPS. Marcella, all of the other coordinators myself, we all have PPS so we can supervise those clinicians. And that was pretty complicated. Sorry. But that was the simplest I can provide.
That was great and I think the comment that you made about three years ago you didn’t know any of that. Because I was about to ask, how the heck do you know all these things? For folks that are… SCOE is massive and you have so many things going on and have for a long, long time.
Some of the other counties or even districts who are looking at this more collaborative approach, how do you actually learn those things? What was most helpful to you when you were starting out? And you said it was partnerships. I don’t know if either of you could speak more to that. What was the most helpful thing maybe for you all to really start moving this work?
Yeah, I’ll take a first crack at this, Marcella, and then would love for you to jump in. Remember back to that second slide, our tenets. The very first tenet is relationships. The way that Marcella and I introduced ourselves today is the way that we introduce ourselves all the time. I tell a little bit about my story. I tell people where I’m from, I try to use humor.
And we have developed relationships with our county partners. We’ve literally gone to the health center with boxes of donuts and coffee and sat next to people at their cubicles. And been like, “I don’t know what you’re talking about. Can you please help?” And just being, leading with humility I think, and saying, “I don’t know anything of this. Please help me.”
But very first and foremost, setting a vision and saying, “Look, I was a kid who almost dropped out of high school. My brother did drop out of high school because when our parents divorced, we were set adrift and we didn’t know what was up and what was down. And I needed somebody in my school to care about me and I didn’t have anybody. And so now, I’m really focused on providing those folks in schools for the kids who like me and the kids who have it way worse than I did.”
When folks can buy into that vision and then we sit next to them and literally say, “It doesn’t matter how many initials I have after my name or what my title is, I just want to learn. And can you help?” I think folks really buy into that. And so when we say start with relationships, we really mean it. Start with relationships. Be humble, admit what you don’t know, and ask for help. Marcella.
Yeah, yeah. Chris, you said buy-in, and it is deep trust that you’re building. Relationships are absolutely key. Well, I speak I guess maybe for myself, roll my sleeves up and dig into the weeds. We’re all humans working in a humanistic system, working alongside one another.
And the goal truly, the vision is to develop sustainable—sustainable—school-based mental health and wellness services. How many times have we all been funded on grants? And, grants, they’re phenomenal. They support the startup of services just beautiful. I’ve supported the writing of grants.
But we come in, we do these needs assessments and we promise the world to our communities, oftentimes the most underserved members of our communities. In three years, what happens? Those services disappear. And so, yes, ensuring that all members identify a common vision, developing school-based mental health and wellness services, identifying the needs.
Chris mentioned at beginning suicide. It’s the second leading cause of death for our youth and our black and brown children are even higher than their white peers. If not now, then when? If not now, to imagine the possibilities of what we can develop in service of our children, youth, families. And of course, working alongside one another, then who, then when?
And so certainly, developing trust alongside partners and asking what can feel like the silly questions, but truly being humble and saying, “I don’t know.” Provider classes, that I believe that was one of the questions. Saying, “Help me understand under the FQHC world what that means. I recall the EPSDT world. I remember SMA world. Random woman in time, connecting that to the same SMA.” But just truly, truly building relationships, asking the questions, and engaging in the work alongside other humans.
Jenny, I just want to provide one point of clarification because I’m seeing a couple questions pop up here. Within the FQHC SMA, this, again, we’re bridging systems, the health system and the education system. We’re bringing these systems together in a way that we haven’t done before. The health system, billing FQHC you have to be licensed through the board of Behavioral Sciences, LCSW, LMFT. Clinical psychologists as well. Currently, we don’t have any clinical psychologists on staff.
In an education setting to do this type of work, you need a credential and that’s the pupil, personnel services credential, a PPS credential. To bring these two things together, you can be a licensed clinician and work in a school setting without a PPS, but you have to be supervised by somebody with a PPS. Because at the end of the day, it’s a school setting, which is a local education agency, LEA.
We don’t require our clinicians to have a PPS, but the folks who supervise the clinicians have to have a PPS. That’s as simply as I… It’s not a workaround, it’s just the way it is. It’s how are we bringing these systems together. I think hopefully, as the state is really investing heavily in school-based services, we might be able to have conversations around exploring some gray area there, but currently, that’s just the way it is.
I appreciate that and I think it’s always nice when folks have so many of the more specific questions because you know that then they’re actually taking this and going to use the things they’re learning from you all. I’m wondering before we transition to our end, there’s one thing that has come up a couple times that I’m wondering, maybe it’s even a quick, relatively quick answer, but it’s about referral systems and there are so many different ones often for different systems, different agencies. Are you all trying to have a universal referral system? How is that going? What are the connections there?
Yeah. There’s the vision, there’s the “what we want” and there’s the “what is.” So, nothing about our program is cookie cutter. Because as I mentioned, in elementary school serving 160 kids down in River Delta looks very different from a 2,500-student school in the middle of Sacramento City. We have to attend to that.
We want everybody to have a referral system and some schools, like Sacramento City Unified has been doing mental health services for years. They have referral systems. Great, can we just use yours? Down in River Delta, they don’t have a referral system, then we say, “Well, here’s one. Will this work for you?” And I think what we’d love to get to is an integrated system that includes behavioral health, like access referrals, the FQHC, and what we’re doing and maybe something like CPS. Or it would be great if all agencies could work in that no wrong door approach, like that one referral and then the agencies work it out.
And the county is in partnership with all of our agencies working on what they’re calling a social health information exchange. We hope that that will streamline this, but there’s other considerations around that as well, around a universal ROI or a release of information. Currently, the short answer is we want every school to have a referral system that is unique to their students. We have a template that we will introduce to schools, but we don’t force anybody to do anything. We try to lead through influence rather than authority.
Woo! Thank you. I mean, what an amazing “also” statement to end on, right? As we move into our last few slides here, influence rather than authority. I might have to sit on that for a little while. Thank you again, Chris and Marcella, for your insights. We also thank all of you for joining us and engaging in the conversation. We hope to see you with some of the other sessions today, and with that, we say goodbye for now.