A model of collaboration: Public education and public health working together in Berkshire Hills Regional School DistrictMore Info
Great Barrington — Muddy Brook Regional Elementary School principal Mary Berle announced this past week in a letter to the school community that she’d be stepping aside at the end of this school year. She’s been in her current position since 2014.
One of her legacies at the school of 348 pre-kindergarten through fourth-grade students will surely be the multisector collaborative care model she developed with staff to serve the complex, changing behavioral and social emotional health needs of her students and families. Today, through this approach and with the extensive support of several community partners, scores of students across all three Berkshire Hills schools are served by a range of wraparound mental health, nutritional, medical and social services. With the help of this “village,” classroom teachers are able to focus better on what they’re trained to do–teach academic content–and kids and their families are accessing the help they need.
According to a study through the National Center for Biotechnology Information, the collaborative care model “is an integrated approach to improving access to mental health services in primary care settings, [and] may be a particularly useful model to address barriers to quality mental health care and improved outcomes for youth in schools. CC is focused on delivering patient-centered, population-based care using a team of coordinated providers.” Its emphasis is on “reducing access barriers, improving service quality, and lowering healthcare expenditures.”
Current key partners in the collaborative care model, in addition to the building principals, are Dr. Deborah Buccino and registered nurse and care coordinator Adrien Conklin at MACONY Pediatrics and Adolescent Medicine. School nursing staff, clinicians, counselors, teachers and administrators round out the teams that meet regularly to coordinate plans for individual kids. Also currently involved in referral, consultant and funding roles are Brenda Butler, M.D., medical director of child and adolescent psychiatry at the Brien Center and Berkshire Medical Center; Austen Riggs Center; the Brien Center; Berkshire United Way; and Berkshire Taconic Community Foundation.
During Berle’s first year at Muddy Brook as principal, students’ emotional needs predominated and seemed impossible to meet. The previous administration had warned her “There’s nowhere to call.” The school then had one overwhelmed adjustment counselor. Berle recognized that she had to build connection with the health care community and shift the counselor’s role to include connecting families with services beyond the school. She enlisted help.
Ed Shapiro, former CEO and medical director of Austen Riggs, spent 40 volunteer hours with Berle that first year, helping her clarify what the school could and should manage, and what required outside interventions and assistance. “His takeaway was it’s critical to know what is education, and what is healthcare, and to come up with partnerships and systems to address both.”
In that year she ended up making 34 referrals to various community services including the Intensive Care Coordination program at the Brien Center for Mental Health and Substance Abuse Services, a Pittsfield-based agency that provides “continuum of care for children, adolescents, adults and families who suffer from serious and persistent behavioral health disorders.”
But only two of the cases she referred were eventually managed. Berle and her team tracked the barriers getting in the way of success. They learned that the agency’s policy at the time was to have one of their social workers make three phone calls to referred families and, if they received no response, close the case. It seemed “overwhelmed” was a consistent theme when it came to children’s behavioral health.
Meanwhile, the pediatric staff at MACONY realized they also needed help to make lasting, impactful health changes for their patients and parents. As Buccino recalled, “There were resources out there in the community but without follow up and without a warm hand off to connect our families, they did not understand where to go for nutrition, mental health, housing, social services support.”
To make this “warm handoff,” the doctors and nurses needed an “in” with the schools, the place where kids spend most of their waking hours. Berle, for her part, “had no choice but to build something that let the school be a school.”
Buccino and Berle can’t now remember who called who first with the idea of working together, but do recall, when working on a case together, “..how many additional cases there were and how difficult it was to make progress. We needed a better system and realized it was up to us to make it happen.”
Beginning in 2014, their team started gathering information to understand existing systems, service gaps and communication breakdowns. Through this process they confirmed what seems obvious enough: Public schools alone are not equipped to be behavioral health providers. They also learned new information: that behavioral health referrals on their own often did not lead to effective treatment. Much more was required.
Working with a consultant, they began to clarify the roles and responsibilities for school personnel and their community partners in approaching treatment comprehensively. Berle says, “We worked on each case as it came up and recorded what we tried, what worked, what did and didn’t result in successful outcomes for children. We learned coordination of services was difficult even though families were reaching out and asking for support.”
Using Buccino and fellow pediatricians at MACONY as trusted “bridges” to families, schools were able to navigate and access behavioral health systems successfully. A child’s own pediatrician’s office at MACONY, for instance, could become the place for an Intensive Care Coordination intake with the Brien Center, eliminating the middleman. “Families have no idea what an Intensive Care Coordination team is, they just want a therapist.”
MACONY nurse Conklin soon emerged as the point person, the bridge who offered that warm handoff, who got to know all the key players and the types of insurance they’d accept. She’d come from the visiting-nursing field and had learned that effective, honest communication had to be the core of the work. “It was so clear when I started in this position that this lack of communication was the missing piece for so many of these families. One hand often didn’t know what the other was doing–school and medical, school and behavioral health, behavioral health and medical.” Nobody in the school community really understood what services were available, either.
She currently is meant to spend about 20 hours of her workweek on the collaborative care program at MACONY Pediatrics, but usually spends much more. She now calls her work “a lifestyle job,” one that requires her to make and answer calls at 10 p.m. on a Friday night or 7 a.m. a Saturday morning. “I have to be flexible,” she says. “Many parents work full time and can only talk early Saturdays.” During the intense period when a child is first referred to the program, she may be on phone with parents a few times a week until they are all linked in, a child’s meds kick in and therapy is starting to make a positive impact. Conklin is at the school two or three days per week.
But it’s all worth the effort and time, she insists, because the approach is innovative and it works. “It’s so incredible to revamp what we think about what nurses can do. To think beyond the nurse in the office and hospital, and make bridges between support agencies and school staff and outpatient therapists. It’s amazing to expand that role.”
Conklin keeps an Excel spreadsheet, her master list of all the myriad providers and services in the area. She knows “one therapist who’s good with quirky kids, or younger kids, or this male therapist is good with a kid who needs a strong male figure. Matching kids to the right therapist is just as important as finding a therapist in the first place.” Before, school counselors might have looked at a random list of providers and suggest to parents, “Try this one.”
Parents are excited to have support since, in the past, they’d have been navigating all the systems and rules on their own. Adrien interprets their standard reaction as, “Wow, that exists?? Thank you!”
For many parents, meeting with a nurse is far less stigmatizing than meeting with a social worker. The child’s pediatrician, of course, they have often known from birth. “You can have the conversation with your doctor that you can’t have with the child’s 1st grade teacher.”
For doctors, the collaborative approach helps with, among other things, the issue of professional burnout. “Before,” says Buccino, “you saw parents struggling, and in their follow up appointment they are in the same situation as before. It’s demoralizing. But if their care is being taken of collaboratively, and needs are getting addressed, it’s invigorating for us.”
As the various pieces of the collaborative care model were implemented, staff within the Muddy Brook building shifted resources away from crisis intervention to systems intervention, using a three-tiered system of support. They built the program over time, adding, in 2015, a clinical social worker and, in 2016, a special education teacher. Berle and staff developed a therapeutic classroom with a full-time special education teacher and clinician, two new positions which, in 2016, the school committee agreed to include in the budget (initial funding for the RN care coordinator role outside the school budget, came through the Berkshire Visiting Nurse Association through Berkshire Health Systems).
Now, clinicians have a workable caseload within the building and they are the lead communicators with Conklin. All have permission–thanks to extensive, regularly updated parental consent forms–to be in larger conversations with families to align services. Clinician Colleen Meaney now sees between 20 and 30 kids per day, and runs groups on such things as how to deal with anxiety, anger and self-regulation. “Big feelings come up and kids don’t know what to do. We learn coping strategies.” She also responds to calls from teachers and kids will ask for her. Also, this year, she is working with whole classrooms on mindfulness techniques.
On the day of our interview, Conklin had just consulted with yet another team member, the school nurse, Becky Donovan, about care for a student. Says Donovan of the way it used to be for her in trying to get care for a child, “Usually you’re waiting days to hear back from a doctor’s office.”
The school adjustment counselor’s role has shifted, too, from unmanageable crisis management to a combination of direct service, sourcing outside referrals and working with community partners.
In 2016, the Collaborative Care Team served a total of 125 families representing 12 towns. Fifty of those families had complex psychosocial problems and received, through the team, connection to transportation, housing, Head Start, daycare, nutrition services and Community Health Programs and United Way family services. Successful referrals to mental health providers dramatically increased. Through the Brien Center and work with local therapists, 20 children with severe behavioral issues warranting placement outside the classroom were served. Most were able to stay at school rather than be sent out-of-district to therapeutic schools at taxpayer expense. Thirty families total were connected to mental health services for the first time despite previous unsuccessful attempts.
Says Berle, “This structure means families, school and health care staff work together and support for children is aligned at home, school and in the community. Students get the support and care they need and teachers can focus on teaching. Nobody works in isolation. Without that they get lost. With just school, the kids keep having the same classroom problems. With just the doctor, it’s the same health problems every time.”
Among the challenges that often contribute to children’s behavioral health problems are a range of family crises. These often include some combination of addiction, mental health problems or complex medical needs. Perhaps there is a grandparent raising a child whose parent has lost custody. Then the grandparent passes away and a previously absent mom has to step in but doesn’t know what to do.
Meaney said, “I don’t think most people outside of school understand what goes on, how every year the kids’ needs increase.”
As for the future of the collaborative care model at MBRES, without the leadership of Mary Berle, there’s still much to do and a solid foundation from which to build. Unfinished work includes additional professional development for school staff on social-emotional learning and implementation of a school-wide social and emotional curriculum. Local author and pediatrician Dr. Claudia Gold has gotten involved to look at ways to impact families prenatally and, along with Amy Taylor, the South County community liaison for the Berkshire United Way, focus on getting infants and children ages 1 to 5 ready for school (recent collected data revealed that between 30 and 40 percent of incoming kindergarteners to Muddy Brook are not ready for kindergarten).
Sustainable funding will be the program’s biggest challenge. About half of the referred students benefiting from collaborative care are on MassHealth, and fewer and fewer private therapists are willing to take it. Just in the past couple of weeks, two of Conklin’s most consistent therapists told her they were going to stop taking MassHealth because of the difficulty in getting reimbursed. One had not been paid for her services for eight months.
Coordinated care in general isn’t well funded in the medical system. With constantly shifting priorities and mandates, from a shift to outcome-based payments instead of a fee for service model, the industry is not yet at a place where insurance companies are reimbursing for these types of services for pediatric patients. Buccino says, “Maybe in two years what we’re doing will be a part of what insurance covers but we need a bridge and system of funding to get there or much of our current successful collaborative care coordination may be lost.”
Berle asserts that we as a people need to make decisions. “What is our community’s commitment to meeting the social and emotional needs of our children? Everyone says this model is remarkable and it works, but there’s so little money for it. Every child that is met and supported well at an early age will contribute to our safe and thriving community as they grow.”
She is hoping that their collaborative care model will benefit from a rural health grant recently received by Fairview Hospital. Two upcoming community meetings will gather citizen input on how to spend that money: Wednesday, Feb. 21, 6–8:30 p.m., First Congregational Church in Great Barrington; and Friday, March 23, 1–3:30 p.m., Stockbridge Town Hall Community room. Pizza will be provided.
Year-to-year grants from, say, the Berkshire United Way or a small family foundation can help get things going but are not going to maintain the program. The collaborative care model, she says, needs to be recognized for its effectiveness, and supported by health systems and by public funding sources.
Ben Doren, prinicpal at Monument Valley Regional Middle School, expressed his gratitude to the Berle-Conklin-Buccino team for their hard work in developing the model and added: “Without the program, we would be putting more resources inefficiently to solving problems that do not even surface with the right implementation of the program. I am looking forward to our larger community taking the model seriously and looking for consistent funding structures to make this a guaranteed support for our families in need. This program helps makes education available to all students.”
Berle also ended her comments on a hopeful note: “I’ve learned that when we have the courage to name the hardest challenges and ask for help, the collective capacity and will exists here to innovate and create systemic change. The future of public schooling is dependent on the school community and health care systems working collaboratively in thoughtful ways.”