WHO’S CARING: The state of school-based mental health care in NYC schools Gale A. Brewer Manhattan Borough President 1 Dear Manhattanite: Students do better when their schools have available mental health services. Yet when public school students return to class this fall, many will be heading to campuses with no school- based mental health providers. Across Manhattan, there is roughly one social worker for every 800 students, and dozens of schools have not a single social worker on staff. Those schools are covered by a patchwork of consultants and mobile response teams, none of which can offer the same level of care as a school-based provider. The following report—based on interviews with school leaders and mental health professionals and data from the Department of Education and the Department of Health and Mental Hygiene—examines the current landscape of mental health services and the challenges that schools face when it comes to providing on-site care. Sincerely, Gale A. Brewer, Manhattan Borough President 2 Introduction The availability of mental health services in schools has been linked to better educational outcomes, and reduced suspensions and absenteeism.1 School leaders and health care providers agree that school-based mental health services have tangible, positive impacts on a school’s climate. It leads to a school-wide culture where students feel safe and comfortable asking for both academic and socio-emotional help. Educators should be equipped with the tools to help students in crisis, knowing they too can turn to mental health experts and that they are not expected to be educators, social workers, and disciplinarians all at the same time. “All signs point All signs point toward better outcomes for students and teachers when there is greater access to mental health care providers on-site toward better at schools, but the services currently offered in New York City’s public outcomes for schools are falling short. students and Nearly 40% of the young people in the U.S. who need mental teachers when health services do not receive the treatment they need.2 The numbers there is greater are even more dire along racial and socio-economic lines, with 45% of students in poverty, 55% of Black students, and 46% of Latino students access to mental never receiving necessary mental health services. These unaddressed health care mental health needs pose serious consequences, placing young people providers at a higher risk of academic underperformance, substance abuse, on-site…” unhealthy relationships, isolation, and suicide. In New York City, nearly 237,000 children under 18 have a diag- nosable mental health condition according to the Citizen’s Committee for Children in New York. It is our duty to do all we can to facilitate mental health crisis care within a public school setting. School is often where symptoms for mental health disorders first become apparent. Increasing school-based mental health services will help normalize mental health treatment and allow children to connect with treatment in a setting in which they are already familiar. New York City public school students come from over 182 countries, 42% of them speak a language other than English at home, and over 500,000 New Yorkers are undocumented and uninsured. Throughout our study, school leaders explained that they lack adequate training on how to address legal concerns of undocumented students and parents. Additionally, many school leaders shared they lack the staff needed to communicate with students who need services and 1 Child Mind Institute. “2016 Child Mind Institute Children’s Mental Health Report.” 2016 Child Mind Institute Children’s Mental Health Report (2016): n. pag. https://childmind.org/report/2016-childrens-mental-health-report/ 2 Children’s Defense Fund. “The State of America’s Children.” Children’s Defense Fund. N.p., 2014. http://www.childrensdefense.org/library/state-of-americas-children/ 3 information in languages other than English. Further, many school leaders say they lack clarity on what to do in case of a mental health emergency, or what even constitutes such an emergency. There is little guidance or training on crisis-based interventions, or a comprehensive referral process. Since the 2016 presidential election, educators across the country have reported that incidents of harassment in schools have skyrocketed. With a Trump presidency, as we gear up for another 3 1/2 years of hard questions on some of the most pressing issues from immigration to police reform to reproductive rights, it is more important than ever that our schools are safe havens for our students and that teachers and other staff have the resources they need to respond when students are in emotional crises. As a city we must renew our commitment to making sure every child has access to culturally appropriate school-based mental health services. This report examines the landscape of Manhattan’s school- based mental health services as of 2016. We spoke to mental health providers and school officials and gathered data from the Department of Education and the Department of Mental Health and Hygiene to get the full picture of mental health services available at schools across Manhattan. We identified challenges that schools and service providers face and developed recommended actions for city and state agencies to fill gaps and ensure mental health services are permanently accessible in all New York City public schools. The Landscape: In New York City, school-based mental health services are licensed and put into place by multiple agencies, including the Department of Education (DOE), the Department of Health and Mental Hygiene (DOHMH), the Office of School Health (OSH) and New York State’s Office of Mental Health (OMH). In October 2015, First Lady Chirlane McCray announced a plan called “ThriveNYC: A Mental Health Roadmap for All,” comprised of 54 initiatives aimed at reducing stigma for mental health issues and closing treatment gaps. As part of ThriveNYC, mental health resources were added to schools with low graduation rates, student achievement, and attendance, which are called Community and Renewal Schools. Eighteen of the 133 Community and Renewal Schools are in Manhattan. Mental health services at public schools include: School Social Workers: There are 164 Manhattan public schools that have in-house social workers, which they primarily pay for through 4 their students’ individualized education plans (IEPs). These plans are to provide mandated services to special needs students, not to fund services for the general population. Some funding also comes through specific City Council or DOE initiatives focused on providing students with socio-emotional support. In Manhattan, we have over 177,000 students, yet only 221 school- based social workers in just 164 schools. That breaks down to roughly one social worker for every 800 students. Citywide, the DOE employs 1,183 social workers in New York City public schools, or approximately one for every 900 students. School-based clinics, which fall into two categories: “Out of Article 28 clinics: There are 103 Manhattan public schools with Article New York City’s 28 clinics, which are regulated by OSH and are a collaborative effort 1.79 million between the DOE and DOHMH. Article 28 clinics are primarily located in under-served neighborhoods and provide on-site primary children, care to students.3 nearly 237,000 Article 28 clinics require a fully operational medical room with have a internal constructions, plumbing, and electricity, and a staff with diagnosable multi-disciplinary teams. Teams can include nurse practitioners, mental health physician assistants, and physicians. Many Article 28 clinics also have full-time or part-time licensed social workers who provide mental condition…” health services. Since 2012, New York State has implemented a “carve out” for Article 28 clinics. This allows Article 28 clinic providers to bill New York State directly for mental health services provided, and allows the state to more efficiently process reimbursements. In October 2017, the State will transition Article 28 clinics into managed care. A recent study by the Children’s Defense Fund found that in New York State, Medicaid reimbursements comprise more than 89% of Article 28 clinics’ third-party revenue in New York.4 The study compared current Medicaid reimbursement rates for primary care services to rates that will be set under a managed care payment structure and found that state-wide this could lead to a loss of $16.2 million in revenue.5 New York State’s intent for Medicaid redesign 3 New York City Department of Education. “School-Based Health Centers.” School-Based Health Center - School-Based Health Centers - New York City Department of Education. NYC Department of Education, n.d. 2016. http://schools.nyc.gov/Offices/Health/SBHC/ SBHC.htm 4, 5 Children’s Defense Fund. “School-Based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth.” (n.d.): n. pag. NYS Health Foundation. NYS Health Foundation, 2016. http://nyshealthfoundation.org/uploads/ resources/school-based-health-centers.pdf 5 is to expand access to high-quality care for all New Yorkers, so it is imperative that the transition to managed care for Article 28 clinics is done in a way that does not threaten the financial sustainability of these clinics. Article 31 clinics: There are 62 Manhattan public schools that currently have Article 31 clinics, which are licensed and regulated by OMH. These clinics are satellites of “primary” Article 31 clinics and by definition they host counseling sessions, are staffed by licensed social workers, and operate in a confidential space with floor to ceiling walls. They offer assessments of mental health needs, interventions, consultations with families, and training services for school staff. “With only one These clinics are at a disadvantage because they did not receive the provider per carve-out or additional state funding that Article 28 clinics received.