Domain #4: Evidence-Based Services and Supports Evidence-Based Services and Supports are programs, services or supports that are based directly on scientific evidence , have been evaluated in large scale studies and have been shown to reduce symptoms and/or improve functioning . For instance, evidence-based services and supports are recognized in national evidence-based registrie s, such as Blueprints for Healthy Youth Development, NREPP, and Institute of Education Sciences: What Works Clearinghouse. INDICATORS 1. Number students who received MH services at each Tier 2. Number students who received evidence-based MH at each Tier 4. Reach of services (Likert-style response) 5. All services evidence-based (Likert-style response)
Domain #5: Evidence-Based Implementation Evidence-based implementation is the integration of research findings from implementation science to school mental health care policy, practice, and operations. INDICATORS 1. Have system to determine evidence base 2. Fit with strengths, needs, and cultural linguistic considerations 3. Use training/implementation best practices
Domain #6: School Outcomes and Data Systems School Outcomes and Data Systems captures information about school mental health services, outcomes, and data systems. INDICATORS 1. Number students received mental health services at each tier 2. Number students with documented improvement in psychosocial functioning at each tier 3. Number students who received at least one Tier2 OR 3 service Other outcomes: 4. Number referrals (in AND out of school building) 5. Number referrals which resulted in student receiving services (in AND out of school building) 6. Number students who received a services within 7-days (in AND out of school building) 7. Number out-of-district placements 8. Number inpatient hospitalizations 9. Identifying barriers to implementation of data systems
Domain #7: Data-Driven Decision Making Data-Driven Decision Making (DDDM) is the process of using observations and other relevant data/information to make decisions that are fair and objective . DDDM can help inform decisions related to appropriate student supports and be used to monitor progress and outcomes across multiple tiers (mental health promotion to selective and indicated intervention). INDICATORS 1. Use data to determine interventions 2. Monitor individual student progress 3. Monitor fidelity of intervention implementation across tiers 4. Aggregate student mental health data 5. Disaggregate student mental health data
NATIONAL SMH PERFORMANCE DOMAINS SUSTAINABILITY
National SMH Performance Measure Domains: Sustainability • CSMHS "Sustainability ” – refers to the financial and non-financial dimensions of maintaining or supporting a self-sustaining system over time, in which its operational structure and capacity is sound and can evolve and adapt to match the changing needs of students, families, schools, communities, and other systems in their context.
CSMHS Sustainability Domains • Funding and Resources • Resource Utilization • System Quality • Documentation and Reporting of Impact • System Marketing and Promotion
Domain #1: Funding and Resources Funding and resources refer to strategies in place to leverage and apply various financial and non-financial assets in your District’s CSMHS. INDICATORS 1. Use multiple and diverse funding 2. Rely on strategy of leveraging 3. Have adequate funding at each tier 4. Have strategies to retain staff
Domain #2: Resource Utilization Resource utilization refers to the extent to which your CSMHS is actively accessing and maximizing the financial and non-financial assets available or potentially available to your system. INDICATORS 1. Use stakeholders to support professional development 2. Access updated resource map 3. Monitor policy 4. Use third-party reimbursement 5. Maximize opportunities to bill 6. Provide continuum of care
Domain #3: System Quality The quality or standard of services and supports provided to students and families is highly important to system sustainability. Fundamental aspects of quality including use of evidence-based services and supports, regular use of data for decision making and youth and family partnership are included in this section. INDICATORS 1. Use evidence-based services 2. Use data to inform decision-making 3. Involve youth and families in CSMHS
Domain #4: Documentation and Reporting on Impact It is critical to document and report on the impact of your system to a wide range of stakeholders who play a role in your system’s sustainability. These activities can also support your advocacy for the system’s maintenance, growth and change in many ways over time. INDICATORS 1. Document academic impact of CSMHS 2. Document emotional/behavioral impact of CSMHS 3. Document impact CSMHS sustainability factors 4. Report overall impact of CSMHS
Domain #5: System Marketing and Promotion It is critical to actively market and promote your system to a wide range of stakeholders who play a role in your system’s sustainability. INDICATORS 1. Disseminate findings to community 2. Market CSMHS to school district leaders 3. Market CSMHS to non-education partners
CSMHS CoIINs • Goals: 1. Test practices that result in increased quality and sustainability 2. To help guide CSMHS to think creatively and strategically to increase quality and sustainability in their system 3. Disseminate promising practices and lessons learned in the field Currently accepting applications for CoIIN cohort 2 http://csmh.umaryland.edu/
CoIIN Methodology
CSMHS CoIINs – Cohort I sites Stamford Public Schools, Stamford CT Methuen Public Schools, Methuen MA Newport-Mesa Unified School District, Costa Mesa CA Lindsay Unified School District, Lindsay CA Novato Unified School District, Novato CA Racine Unified School District, Racine WI Baltimore City Public Schools, Baltimore MD Mental Health Center of East Central Kansas, Emporia KS Minneapolis Public Schools, Minneapolis MN Metropolitan Nashville Public Schools, Nashville TN Proviso East High School, Maywood IL Chicago Public Schools, Chicago IL
Methuen Public Schools- Example PDSA - Screening • Two large scale screenings at Methuen High School • GAD-7 anxiety screener (January) • PHQ-9 depression screener (April) • Electronic screening using Google forms • Parent notification and opt-out process established in advance of the screenings to secure passive consent. • Administration during the school’s advisory block. • Data review and coordinated follow-up planned for both screenings. • 100% of students who required follow-up received it within 7 days of the screening.
STANDARDIZED NATIONAL PERFORMANCE MEASURES FOR SBHC S
Meeting the SBHC field where it is • SBHC field has no history of requiring standardized data documentation or reporting at the national level • Variability across states in the definitions of measures, methods of data collection, provider capacity, data quality, and funding to support initiatives • However, several statewide performance measurement initiatives have been successful • QI initiatives to document and report quality of care have improved care delivered in SBHCs • Collection of data has allowed states to explain the value- add of the model and advocate for SBHCs Opportunity to build on successes and lessons learned!
Background research – national level • Conducted expert interview • Examined national child health initiatives with quality improvement components CHIPRA CMS HEDIS UDS USPSTF
Background research – state level • Interviewed state SBHC program offices who require performance data reporting as a requirement of funding
Core Set of Standardized National Performance Measures for SBHCs • Align with national child health care quality measurement • Capture the uniqueness and value-add of SBHC model through: • Increased seat time • Easy access to health care due to location in schools • Improved experience of care • 90 stakeholders participated in three rounds of voting in modified Delphi method
Standardized National Performance Measures for SBHCs BMI screening and Annual well Annual risk nutrition/physical child visit assessment Core activity counseling Depression screening Chlamydia screening Stretch SBHC student user Student disposition log (seat time saved) survey
Five core performance measures for SBHCs BMI screening and Annual well Annual risk nutrition/physical child visit assessment Core activity counseling Depression screening Chlamydia screening Stretch SBHC student user Student disposition log (seat time saved) survey
SBHC core measure #1: Annual well child visit Percentage of unduplicated SBHC clients who had at least one comprehensive well-care visit with a primary care practitioner or an OB/GYN practitioner during the school year, regardless of where exam was provided, including documentation of: Health and developmental history AND Physical exam AND Health education/anticipatory guidance
ANNUAL WELL CHILD VISIT Numerator A: Number of unduplicated SBHC clients Numerator B : Number of unduplicated SBHC clients who had at who had at least one comprehensive well-care visit least one comprehensive well-care visit provided by non-SBHC Numerator provided by the SBHC during the school year provider during the school year Denominator: Number of unduplicated SBHC clients who had a least one visit of any type to the SBHC during the school year Denominator HEDIS i : http://www.ncqa.org/portals/0/Adolescent%20Well-Care%20Visits.pdf Source 0-21 years old Age Range CPT: 99381-99385, 99391-99395 Suggested claim/ ICD-9: V20.2, V70.0, V70.5, V70.6, V70.8, V70.9 encounter codes ICD-10: Z00.121, Z00.129, Z00.00, Z00.01 Source: HEDIS: http://www.ncqa.org/portals/0/Adolescent%20Well-Care%20Visits.pdf) Number should not include typical or traditional sports physicals, unless the sports physical is done as part of a comprehensive Inclusions/ well child visit Exclusions In order to qualify as comprehensive, a well-child visit must include documentation of health and developmental history; physical exam; and health education/ anticipatory guidance i HEDIS: National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set
CoIIN example: How are SBHCs capturing WCV outside the SBHC?
SBHC core measure #2: Annual risk assessment Percentage of unduplicated SBHC clients with ≥1 age-appropriate annual risk assessment during the school year
ANNUAL RISK ASSESSMENT Numerator: Number of unduplicated SBHC clients with documentation of ≥ 1 age-appropriate annual risk assessment during the school year Numerator Denominator: Number of unduplicated SBHC clients who had a least one visit of any type to the SBHC during the school year Denominator State govt. definitions (IL, LA, MA, ME, MI, NC, NM, OR) Source Age range of SBHC client population Age Range 99420 & 96127 (CPT) Suggested claim/ encounter codes Source: AAP: https://www.aap.org/en-us/professional-resources/practice-support/financing-and- payment/documents/bf-pmsfactsheet.pdf AMA: www.apapracticecentral.org/update/2015/02-26/coding-changes.aspx
SBHC core measure #3: BMI screening and nutrition/physical activity counseling Percentage of unduplicated SBHC clients aged 3-20 years with BMI >85th percentile with documentation of the following at least once during the school year: • BMI percentile AND • Counseling for nutrition AND • Counseling for physical activity
i CMS: Centers for Medicare and Medicaid Services’ (CMS) Stage 2 of the Meaningful Use Electronic Health Record Incentive Programs ii UDS: Health Resources and Services Administration, Bureau of Primary Health Care’s Health Center Uniform Data System BMI SCREENING iii USPSTF: United States Preventive Services Task Force Numerator A: Number of Numerator B: Number of Numerator C : Number of Numerator D: Number of unduplicated SBHC clients unduplicated SBHC clients unduplicated SBHC clients unduplicated SBHC clients aged 3-20 years with aged 3-20 years with aged 3-20 years with aged 3-20 years with a BMI >85 documentation of BMI documentation of BMI documentation of BMI percentile AND counseling for Numerator percentile in the current percentile during the percentile AND counseling for nutrition AND physical activity school year school year nutrition AND physical activity during the school year during the school year Denominator A: Number Denominator B/C: Number of unduplicated SBHC clients Denominator D: Number of of unduplicated SBHC aged 3-20 who had a least one visit of any type to the SBHC unduplicated SBHC clients clients aged 3-20 years during the school year aged 3-20 years with a BMI >85 Denominator who had at least one visit percentile during the school of any type to the SBHC in year the current school year CMS i , UDS ii , USPSTF iii Source 3-20 years Age Range ICD-9 or CPT: Suggested BMI screening: V85.51-V85.54 (ICD-9) claim/ V85.51 = >5 th percentile (underweight) encounter V85.52 = 5 th – 84 th percentile (normal weight) codes V85.53 = 85 th – 94 th percentile (overweight) V85.54 = ≥ 95 percentile (obese) Physical activity counseling: V65.41 (ICD-9) Nutrition counseling: V65.3 (ICD-9) or 97802-97804 (CPT) ICD-10: BMI screening: Z68.51-Z68.54; Physical activity counseling: Z71.89; Nutrition counseling: Z71.3 Source: UDS Manual; http://www.bphcdata.net/docs/uds_rep_instr.pdf BMI: A statistical measure of the weight of a person scaled according to height Additional definitions BMI Percentile: The percentile ranking based on the CDC’s BMI-for-age growth charts, which indicates the relative position of the patient’s BMI number among others of the same gender and age Source: Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP, March 2015: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/Medicaid-and-CHIP- Child-Core-Set-Manual.pdf
SBHC core measure #4: Depression screening Percentage of unduplicated SBHC clients aged ≥12 years with documentation of the following at least once during the school year: • Screened for clinical depression using an age appropriate standardized tool AND • Follow-up plan documented if positive screen
DEPRESSION SCREENING Numerator A: Number of unduplicated Numerator B: Number of Numerator C: Number of SBHC clients aged ≥ 12 years with unduplicated SBHC clients unduplicated SBHC clients aged documentation of screening for clinical aged ≥ 12 years with a positive ≥ 12 years with a positive depression Numerator depression using an age appropriate depression screen documented screen AND follow-up plan standardized tool during the school year during the school year documented during the school year Denominator: Number of unduplicated SBHC clients aged ≥ 12 years who had a least one visit of any type to the SBHC during the school year Denominator NOTE: The components of this measure will be calculated from these four data points. UDS, CMS Source ≥ 12 years Age Range ICD-9: V79.0 Suggested claim/ encounter codes ICD-10: To be added (also RAAPS code) CPT – II = 3725F; 99420; G8431 (positive screen); G8510 (negative screen) Source: UDS Manual; http://www.bphcdata.net/docs/uds_rep_instr.pdf
CoIIN example: How are SBHCs documenting follow- up plan for positive depression screen?
SBHC core measure #5: Chlamydia screening Percentage of unduplicated SBHC clients (male or female) identified as sexually active who had ≥1 test for Chlamydia documented during the school year
CHLAMYDIA SCREENING Numerator A: Number of unduplicated Numerator B: Number of unduplicated female male SBHC clients identified as sexually SBHC clients identified as sexually active who active who had ≥ 1 test for Chlamydia had ≥ 1 test for Chlamydia documented during the Numerator documented during the school year school year Denominator B: Number of unduplicated Denominator B: Number of unduplicated female male SBHC clients identified as sexually SBHC clients identified as sexually active during Denominator active during the school year the school year CMS, HEDIS Source Age range of SBHC client population Age Range ICD-9: V73.98, V73.88 Suggested claim/ ICD-10: To be added encounter codes
CoIIN example: How are SBHCs capturing sexually active students?
Data collection tips: Documenting five core performance measures for SBHCs • 87% SBHCs report using electronic health/medical record • Use discrete fields whenever possible • Verify CPT and ICD codes are in the EHR • Convert free-text to discrete fields (observational terms) • Be sure SBHC providers and staff are knowledgeable of correct CPT and ICD codes • All providers and staff should use the same codes for these services • Advanced training on EHR recommended to extract and analyze data
Standardized National Performance Measures for SBHCs BMI screening and Annual well Annual risk nutrition/physical child visit assessment Core activity counseling Depression screening Chlamydia screening Stretch SBHC student user Student disposition log (seat time saved) survey
Stretch measures for SBHCs BMI screening and Annual well Annual risk nutrition/physical child visit assessment Core activity counseling Depression screening Chlamydia screening Stretch SBHC student user Student disposition log (seat time saved) survey
SBHC stretch measures: Client disposition log (seat time saved) SBHC providers would track what happens to client at the end of each visit (paper or electronic log): • Student disposition after services for acute illnesses: 1) Sent back to class; 2) Sent home; or 3) Sent to ER. • Documents classroom seat time (or absences) saved due to having SBHC on-site (i.e., % clients sent back to class vs. sent home) • Does not involve linking SBHC data with academic records
SBHC stretch measures: SBHC student user survey Standardized survey completed by SBHC or sponsor agency representative annually assessing the following measures/domains related to policies and procedures (among others): • Easy access to health care due to location in schools • Referral completion policies and procedures • Integrated primary and behavioral health care • Care coordination policies and procedures • Medication administration services for all students • Confidentiality policies
Examples of SBHC stretch measure in the field • Seat time saved • Alameda county (California) • West Virginia • SBHC student user survey • YEHS! (Colorado and New Mexico) • Adolescent and Youth Adult Health National Resource Center Opportunity to build on successes and lessons learned!
SUSTAINABILITY MEASURES FOR SBHC S
SBHC sustainability measures Primary care School population SBHC client appointment enrolled in SBHC utilization capacity used Client health Visits reimbursed Primary care insurance by health provider efficiency coverage insurance Behavioral health provider efficiency
SBHC CoIIN Teams Public Health – • Text Colorado Department of Seattle & King County Public Health and Education School-Based Partnership Standardized Program 10 SBHCs Performance 7 SBHCs Measures Connecticut Department of CoIIN Public Health and North Carolina School-Based Connecticut Association of Health Alliance School Based Health Centers 10 SBHCs 10 SBHCs Bassett Healthcare Growing Well Network Cincinnati, OH Cooperstown, NY Sustainable 5 SBHCs 4 SBHCs Business Practices CoIIN Minnesota Department of YMCA of the East Bay Health, Child and Richmond, CA Adolescent Health Section 5 SBHCs 11 SBHCs
Lessons learned from SBHC CoIINs • This work is challenging, even for the experts and early adopters! • Direction health care is moving – recognizing reward • Data become easier to extract and report • Opportunity to use data to drive decisions • CoIIN sites testing strategies to determine best practices that SBHCs nationwide could adopt to: • Overcome data collection and extraction issues with innovative approaches • Create processes that account for the variability in the types of data and the ways of collecting data • Reduce burdens for nationwide SBHCs to participate in reporting the standardized national performance measures
NATIONAL DATA COLLECTION SYSTEMS
The SHAPE System • The School Health Assessment and Performance Evaluation (SHAPE) System for school mental health systems is an interactive system designed to improve school mental health accountability, excellence, and sustainability. http://theshapesystem.com
SMH Census and Performance Measures: Join Us! • Anyone can Join Us! Health/mental health providers, educators, district school leaders, parents, students. • You will answer a few questions about SMH in your school/district and your school will be counted in the National SMH Census and will receive Blue Star SHAPE Recognition. • You will also receive updates about SHAPE System news and resources.
Drive Quality Improvement and Sustainability in your School/District! • Gather your school or district team and complete the National SMH Census and Performance Measures. • Critical for SMH strategic planning. • Virtual work space for your team to document, track, and advance your quality and sustainability improvement goals. • Receive free, customized reports and action planning guides. • Access hundreds of free resources searchable by topic to hone in on the specific quality and sustainability goals your team is working towards.
http://theshapesystem.com/
National SBHC data repository • Single customized, easy-to-use web-based system for all SBHA data collection efforts • The Census of SBHCs • Standardized National Performance Measures for SBHCs • Decrease reporting burden • Ability to pre-populate data and information reported in previously • Currently, data portal used to collect monthly data from SBHC CoIIN teams • Generates customized reports for SBHCs that include: • individual site-level data reports, • graphs that display quality improvement progress over time, and • information about how each SBHC compares to other CoIIN participants
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