Baltimore Expanded School Mental Health Report of the Program Evaluation Appendix C: Planning for Sustainability

Transcription

1 Baltimore Expanded School Mental Health Report of the Program Evaluation Appendix C: Planning for Sustainability JOYCE K. SEBIAN, MED BRUNO J. ANTHONY, PHD

2 TABLE OF CONTENTS SETTING THE STAGE FOR SUSTAINABILITY PLANNING... 3 ORGANIZING FOR SUSTAINABILITY... 4 Developing a Financial Plan... 5 Developing a Communication Plan: One Baltimore ESMH Program... 5 Tackling Adaptive Challenges... 6 Addressing Infrastructure... 7 THE MESSAGE OF BALTIMORE ESMH... 7 DEFINING SUSTAINABILITY PLANNING... 8 QUESTIONS TO GUIDE BALTIMORE ESMH SUSTAINABILITY PLANNING... 8 ACTIVITIES FOR CONSIDERATION: ADDRESSING SUSTAINABILITY OF BALTIMORE ESMH RESOURCES... 13

3 SETTING THE STAGE FOR SUSTAINABILITY PLANNING Students in the Baltimore City Public School System (BCPSS) are making real and measurable gains from their participation in the Expanded School Mental Health (ESMH) Program (see ESMH Evaluation Report). Baltimore s ESMH services have complemented and supplemented the services provided by BCPSS (social workers, psychologists, and guidance counselors). Over time, the ESMH program has grown to include services in over one hundred and six of Baltimore s elementary, middle and high schools across the City. In this era of accountability, and as new and past leadership plans for the future and prioritizes the allocation of limited resources, accountability and quality assurance is pivotal. Baltimore ESMH has managed to sustain and grow in strategic areas over this past decade. The program s success in achieving a new decade of sustainability is linked to questions about the return on investment and the ability of the program to work effectively, efficiently and collaboratively to achieve the desired outcomes. Over the past year, Georgetown University s Center for Child and Human Development has conducted an evaluation of the ESMH and the Expanded School Behavioral Health Initiative (ESBHI; see Appendix B), a related program designed to provide targeted mental health and substance abuse prevention services to 6 th graders at- risk of drop- out who are enrolled in 37 identified schools. The data and findings from this work are intended to inform sustainability planning in the coming months and years. The encouraging findings indicate what many noted in early interviews with the Georgetown Evaluation Team; the ESMH Program is getting results- students are showing improvements in key educational indicators and behavioral health factors, all linked to improved education and academic outcomes. The shift from anecdotal stories to hard data provides documentation that is validating and critical. This data will facilitate the ability of the ESMH program to sustain and expand fiscal support for the program and to maximize use of existing resources (both fiscal and non- fiscal). The findings document the positive impact of the Baltimore ESMH program and ESBHI and also raise important questions for further evaluation. The findings have social and economic implications for city, state and national entities concerned with improving child health and mental health and improving the educational outcomes for Baltimore, Maryland and our nation s children. Further investigation and lessons from other prevention/intervention studies show the potential for significant cost savings and reduction in behavioral health risks and problems in children and youth. Cost and benefit assessment and savings across systems is an area for further evaluation. There is no doubt that necessary advances in the care of youth with mental health challenges attending BCPSS have been hindered by a number of factors including, but not limited to: 1) inadequate funding and fierce competition for rapidly shrinking resources; 2) lack of use of consistent and effective strategies for addressing these challenges; 3) a lack of appropriate training for providers in evidence informed practices and their integration into the school setting, and 4) a crisis management and survival mentality that prevents collaboration toward long- term solutions. Below we outline a number of critical planning activities that will contribute to continuous quality improvement and long- term 3

4 sustainability of the Baltimore ESMH. The Georgetown Evaluation is a starting point for further and ongoing data and evaluation efforts that will inform decisions linked to quality assurance and to sustainability. This report provides strategies for building sustainability that have been informed through an array of activities within the BESMH Evaluation. These activities include: Review of the literature on financing of school mental health and behavioral health programs; and review of literature on sustainability of school based mental health programming in particular. Interviews with experts on school mental health programs with a focus on expanded school mental health and financing. These included: Mark Weist Ph.D., Director, Center for School Mental Health and professor of Clinical Psychology, University of Maryland; and Mark Sander, Coordinator, Expanded School Mental Health Program, Minneapolis, Minnesota; Krista Kutash, Ph.D., University of South Florida. Focus groups and key informant interviews conducted with key BESMH stakeholders including: the BCMHS Program Director, Coordinator, 6 th Grade Initiative Program Director, and advisory committee meetings, communications with BESMH Coordinator, communications with BESMH Program leaders, meetings with Baltimore City Public Schools and general observations Many of the BESMH partners and the evaluation team provided information and insights during the evaluation process. Additionally, the Georgetown team members have participated regular meetings addressing planning and implementation of the program. Organizing for Sustainability The Baltimore ESMH Program may benefit from expanded partnerships that frame ESMH within a broader strategic and comprehensive public health initiative to create healthy communities, schools, neighborhoods, children and families. Within these partnerships, any specific program is part of the overall strategy endorsed across systems and partners and raises the credibility beyond what it might achieve as a single program. Without this approach, funders may perceive the complex and competing array of services fragmented and inefficient. Funders of all kinds increasingly seek to contribute to efforts for sustainable systems change and to measure impact. They look for clarity from the partners and for engagement of multiple sectors so that the resources are maximized. Any single program is thus viewed within a broader comprehensive and coordinated effort that brings partners together to work towards shared goals, accountability measures, data management systems, outcome data, financing plans, quality assurance systems and strategic, evidence based approaches to address multiple issues and gather data to ensure efficiency and effectiveness in the work to achieve the benefits desired. Some funders (e.g., Coleman Foundation, Kellogg Foundation) are willing to support infrastructure to coordinate collaborative efforts, data systems, and accountability systems. Furthermore, funders, especially private foundations are increasing seeking to assist non- profits in developing organizational systems- to engage tools from business to manage resources effectively and maximize results. 4

5 Positive educational and mental health outcomes are a foundation of the broader asset- based initiatives that seek to foster healthy communities, children and families and are a focus of the ESMH programs. Clarity about these messages requires the processes and tools found in communications and social marketing venues. The work of clarifying questions such as the following is a process of tremendous value. Who are the audiences? What are the messages? How can they be most effectively communicated? What changes in attitudes and behavior are desired? As additional data related to outcome goals and measures are developed and progress towards these goals is monitored, the findings can be tailored to the specific and broader audiences of partners. This data can engage new partners and strengthen the level of commitment of core partners already in place. A plan to move forward with the partnership initiatives to promote sustainability will require that Baltimore ESMH speaks as one voice and includes several components. Developing a Financial Plan A financial plan is needed whether or not Baltimore ESMH aligns with a broader asset- based or public health initiative for the city s children, youth, school environments and neighborhoods in which young people live. A financial plan will serve to bring partners together to set financial goals, to assess current financial and non- fiscal status, to identify strategies for BESMH and it s unique needs to assure quality program services and develop growth opportunities where needed. When a complete financial plan is in place, this can be a tool to appeal across the initiative reaching diverse funders: some seeking smaller discrete projects through a grant- making activity; some seeking to provide in- kind support; and, still others seeking to finance critical infrastructure critical to long term systemic change. Some may find a more suitable fit by supporting a defined element of either ESMH or ESMH as part of the broader community or system change processes. Financial strategies will need to involve leveraging and getting the maximum from current funding streams. A frequent theme in discussions with leaders of the Baltimore ESMH is that the reimbursement for clinical services only covers approximately 1/3 of the cost of the Baltimore ESMH program. This frequently stated assumption is based upon the use of clinician time in the school setting, i.e., time in reimbursable service activities vs. time spent in other important relationship or interventions that are not billable. This also includes time spent in prevention groups, consultation with teachers and families and brief hallway discussions with students. Medicaid is an important provider (and funder) of the BESMH Program. States vary in their Medicaid Programs and it is important to acknowledge that models such as the Medicaid enhancements utilized in the Minnesota ESMH may not apply in Baltimore, still an important question for BESMH to answer is whether they have fully leveraged this funding opportunity. Are there opportunities for further integration of traditional Medicaid services with other funded services? Building upon the strong partnership among the Baltimore City Public Schools, Baltimore Mental Health System, Baltimore Substance Abuse System, the City Health Department and community mental health organizations there seems to be an opportunity for data gathering and building a case for enhanced reimbursement and/or for more integrated funding. It is important also to ask what is the management structure that exists for education based and human services based mental health services and 5

6 to ask if new or enhanced structures are needed to support ESMH in Baltimore and in Maryland. Developing a Communication Plan: One Baltimore ESMH program A ONE Program identity is desired to attract the resources and level of commitment from community, state and national partners needed for long- term sustainability and improved outcomes for Baltimore s children and youth. Recent years have seen the development of network solutions to many of the issues that frustrate success of multi- agency programs. One consultant, Mark Sander, PsyD, LP, Senior Clinical Psychologist, Hennepin County, Mental Health Coordinator, Minneapolis Public Schools, noted that even though ESMH programs can involve multiple agencies which provide services in multiple schools it is important to implement ESMH services as ONE program. How can this be most effectively communicated and who are the audiences for this message? These questions can be addressed in a communications planning process and will further enhance the outcomes of sustainability planning. A communications plan should include strategies for building a ONE BESMH program message that is clear and widely adopted. The steps in developing a total communication and promotion program would further identify the target audiences, determine the communication objectives, design the messages and finally identify strategies to manage and coordinate the total marketing communication process. Tackling Adaptive Challenges New models require new skills, knowledge and resources for creating communications, financing, accountability, data management, quality assurance and organizational management and other systems. The changing context in which programs like the BESMH program and partners operate creates adaptive challenges in which solutions lie outside the current way of operating and can not be provided easily by experts. The context requires new lessons and applications, borrowed from for- profit businesses and translated to the non- profit world. The implementation of a sustainability plan will require that these systems create links across not- for- profit, for profit, governmental and non- governmental entities. A sustainability plan is likely to require shifts that place demands on each partner organization and system. One example includes the non- profit community based mental health programs that provide ESMH clinicians. While contracts are between Baltimore Mental Health Systems (BMHS) and individual mental health agencies, each must respond to the ESMH program needs. Each agency must see the benefits of a linked network (support and collaboration) that benefits the entire program as well as their own activities. Additionally, communications will require varying degrees of change in how the program is communicated to various audiences. Adaptive challenges are required at each level and across systems to create a ONE BESMH message to funders. These changes come through sophisticated communications and financial planning. The economic and fiscal realities compel leaders to adopt new efficiencies, many already underway in the BESMH Program. Partners and contracted agencies, as independent entities apart from the ESMH program are likely to be at varying stages of this transitional process. Thus, the changes needed in BESMHS parallel changes underway in many of the not- for- profit partner organizations. A sustainability plan can take on the tasks of identifying where opportunities for new and 6

7 broader partnerships exist within the City of Baltimore, the region, state or nation, identify how can work be coordinated, and assess opportunities and constraints. A sustainability plan is a critical step towards defining strategies for financing and communications and how they fit together. It can identify opportunities to attract a range of funders who seek to enhance children s health and well- being if there is clarity about how projects fit within the whole and how accountability regarding the results will be achieved. For example, the Baltimore ESMH leaders might examine the possibilities, risks and challenges connected with nesting ESMH within a broader public health initiative as well as the perception, attitudes and behaviors towards a ONE ESMH Program strategy and what particular strategies are needed to firmly ground this across the partners and into the public view. Addressing Infrastructure Infrastructure is important to collaboration in any cross system collaboration initiative. It supports planning and ongoing management needed for sustainability. Infrastructure supports the multi- stakeholder partnerships that make up the BESMH. Activities involving cross system partnerships require time and skilled professional implementation. This infrastructure also provides the institutional memory needed when personnel change or new partners join. The position also serves as a broker to help diverse systems and partners communicate more effectively and understand policy, values and principles integral to the work. These elements contribute to the agility and resiliency of the program to move forward, deepen and broaden the BESMH program, all necessary for the work needed to continue to interpret and shape a shared vision and implement strategies that will be successful in a complex and ever- changing environment. Baltimore ESMH has given priority to infrastructure. A coordinator position is embedded as is the understanding of its role, processes for supervision and other structural aspects of the position are well defined. Regular review and assessment of duties, responsibilities, professional development needs and emerging system needs and gaps are part of other quality assurance processes. Additional indicators include: strong and well articulated partnerships, written contractual agreements, communications protocols, data management systems, problem solving strategies, transparency in communications, articulated values and principles. Partners also understand the importance of valid accountability processes as well as the need for measurement and independent evidence that the desired outcomes are achieved. These assets have enabled the BESMH partners to address and resolve numerous complex and difficult problems and keep moving forward. THE MESSAGE OF BALTIMORE ESMH The challenges of raising and educating children in low- income, urban environments like Baltimore are increasingly recognized as economic issues, affecting business, employment, community health and international competitiveness. Moreover, the moral and ethical issues of ensuring our children have safe, healthy and nurturing environments are recognized through programs such as Promise Neighborhoods, modeled after the Harlem Children s Zone, which offer hope for real change. Significant resources have been made available for these programs through the US Department of Education (US DOE). Beyond Promise Neighborhoods, the US DOE and its partners, including the Substance 7

8 Abuse and Mental Health Service Administration (SAMHSA), increasingly acknowledge that mental health is part of overall health and is intricately linked to educational outcomes. Research acknowledges the importance of these educational outcomes to student success later in life and in future employment. Clear communications strategies can be an important tool to communicate these messages to the audiences needed and help to obtain financing and other resources to support the BESMH program. DEFINING SUSTAINABILITY PLANNING: Sustainability planning is often defined as the process of developing specific strategies and an action plan to help ensure the long- term sustainability of an initiative. It includes considering the full range of resources and competencies financial, political, administrative, managerial needed to meet long- term goals. The Finance Project has identified eight elements of sustainability. These offer valuable guidance to the planners for sustainability of Baltimore ESMH. 1. Vision. Have a clear picture of what needs to be sustained, which starts with clearly articulating what the organization wants to achieve through its work and then clearly identifying the strategies and activities that will get it there. 2. Results Orientation. Define success for the initiative, measure progress over time, and adjust the work based on what is learned. 3. Strategic Financing Orientation. Estimate the resources the organization will need and develop financing strategies and funding sources to provide a stable base of resources over time. 4. Broad- Based Community Support. Consider whose support is needed and develop appropriate outreach efforts and vehicles for community involvement in the initiative. 5. Key Champions. Rally leaders from businesses, faith- based institutions, government agencies, and other parts of the community and persuade them to use their power and influence to generate support for the initiative. 6. Adaptability to Changing Conditions. Be proactive in the policy environment and adjust to changing social, economic, and political trends in the community. 7. Strong Internal Systems. Build strong systems and structures, such as fiscal management, information, personnel, and governance. 8. Sustainability Plan. Create a written plan the organization can use to manage and market its work. QUESTIONS TO GUIDE BESMH SUSTAINABILITY PLANNING Is there a shared understanding of the elements central to the BESMH Program that should be sustained and their definitions? Is there a clear understanding of success? Have the planners clearly articulated what the BESMH partners want to achieve through the implementation of sustainability efforts? Are the strategies and activities clear and understood by all? What measures are currently in place and what additional measures are needed to assure progress over time, and adjust the work based on what is learned? What are the goals, standards and current status of Individual, group and universal services? What is the status of the current work focusing on standards and contractual agreements? What are the activities that are included in these services? How are they defined? Is there agreement about minimum and best practices? These standards, once identified can be further detailed through 8

9 the engagement processes already in place and then built into policy and program implementation. What are the supervisory, reporting and partnership expectations needed for quality and for systematic implementation? What are the billing and reporting requirements and goals? Where is there flexibility? What is non- negotiable? What changes are needed to enhance future outcomes? What are the factors that are most critical to the achievement of desired outcomes? What changes are needed to enhance future outcomes? The scope of the project requires ongoing processes for training and technical assistance. How can the infrastructure support training for current and new clinicians, provider agencies, school personnel (including administrators, teachers, specialists and others), families, youth, City government partners and others to enhance role clarity and service quality. What are supplemental elements of the Baltimore ESMH Program? At each school site, Baltimore ESMH provides a standard set of services. What are those requirements and what can be implemented as optional activities targeted to the particular school and community needs and culture as agreed upon extenders of Baltimore ESMH. From a communications standpoint, there might be a Baltimore ESMH menu thus clearly distinguishing core elements and possible add- ons. Such an effort may be helpful in efforts to mobilize funding resources and engage new partners. Some funding may be tied to a particular school for a unique project or activity. Also, other resources, volunteers, grants, donations and in- kind resources may also be tied to a particular location or project. Clarity will help communicate that the ESMH program is well organized, efficient and effective. It will assist resource providers including funders in knowing where they can be most effective in their philanthropic activities. What are the measures that Baltimore ESMH leadership and partners can use to assess their progress? What are the indicators of success? Additional measures can be identified through a thoughtful process, involving all stakeholders and local assessment experts, addressing priorities and key focus areas. How can clear messages about the benefits of Baltimore ESMH be communicated? What are the opportunities to communicate messages about Baltimore ESMH to a wider audience? Who are the special and unique audiences that may benefit? What are the central messages that can enhance community buy- in and facilitate new partnerships including financing and other resources. How can Baltimore ESMH link to other initiatives geared toward enhancing positive child and youth development, parenting, healthy families and communities- - all part of a broader public health approach. How can Baltimore ESMH services and supports within the school, family, neighborhood or community align with other important efforts that share the goal of influencing the social determinants of health including behavioral health or those risk and protective factors. Common features of treatment, prevention or promotion activities already underway share need to be identified and structured in a way to increase efficiency and effectiveness. Such

10 efforts require flexibility and may entail new strategies for data collection and management. How can Baltimore ESMH move toward effective branding? A comprehensive communications plan is critical to effective sustainability for Baltimore ESMH. The plan might reflect a shared understanding of how marketing and educational resources could further communicate the central messages of Baltimore ESMH, create a clear picture across multiple audiences of importance and begin the work of growing an identity and recognition at multiple levels across the community. As data and evaluation results develop, they can continue to enhance the reputation of the Baltimore ESMH program and support sustainability efforts.

11 ACTIVITIES FOR CONSIDERATION: ADDRESSING SUSTAINABILITY OF THE BESMH Develop a Sustainability Plan Activities: Conduct a strategic planning session with partners from across multiple systems and sectors. Define shared outcome goals, guiding values and principles and measurable activities that will move those priorities forward Identify next steps for implementation and measurement of the plan Integrate the BESMH Program within a Citywide Public Health Approach to Children s Mental Health. Activities: Provide education and resources to engage partners in understanding a public health framework for children s mental health and social determinants of health in Baltimore. Conduct a scan of current promotion, prevention, early identification and treatment programs/activities in Baltimore City Organize and link these programs/activities and the BESMH Program within a framework of a healthy Baltimore City pubic health framework (children, families, schools, and neighborhoods). Assess current public health infrastructure, data resources and interventions that promote healthy children and families, in the context of healthy schools, neighborhoods and community. Develop a Financing plan Activities: Conduct a fiscal and non- fiscal resource mapping study. Identify Financing Goals o o o Develop a cross system true cost financing plan addressing financial and non- fiscal program costs, resources and gaps Suggested elements include: in- school clinician services and supports; training and professional development; Baltimore ESMH coordination; data systems; technology systems; and prevention programs. Develop strategies to achieve true cost reimbursement, funding and new funding streams for essential BESMH services and supports. Develop strategies to achieve funding and resources for add on services and supports. Include unexpected partnerships to meet program needs where possible. 11

12 o Consider current and potential resources to support asset- based activities and data collection/analysis linked to ESMH i.e. school connectedness and school climate. Develop a Communication Plan Activities: Identify and communicate messages about Children s Mental Health and the BESMH to priority audiences. Utilize effective social marketing strategies. Develop products and strategies to reach key audiences including: funders, students, families, education, mental health, public health, business, faith- based, and other leaders from multiple sectors and systems. Develop strategies to foster consistency of messages for BESMH representatives. Train and support BESMH representatives. Infra- structure Activities: Identify core infrastructure needs to support school and clinical/program staff through ongoing professional development and training/technical assistance, including support to new staff and partners. Develop and support infrastructure for current and emerging data collection and reporting priorities. Values and Principles Activities: Discuss and clarify the core values and principles of the BESMH program based upon systems of care and public health. Develop measurable indicators (policy, program and practice) to ensure accountability in implementation. Develop systematic pre and in- service professional development opportunities for partners 12

13 RESOURCES Aos, S., Lieb, R., Mayfield, J., Miller, M., & Pennucci, A. (2004). Benefits and costs of prevention and early intervention programs for youth. Washington State Institute for Public Policy pdf Hayes, C. D. (2002). Sustaining comprehensive community initiatives: key elements for success. Washington, D.C.: The Finance Project. Joseph, M. H., & Connors- Tadros, L. (2011). Sustaining Community Revitalization: A Tool for Mapping Funds for Promise Neighborhood Initiatives. National Academy of Science (2009). Preventing mental, emotional, and behavioral disorders among young people. Washington, DC: Institute of Medicine, National Academy of Science; 13