While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
Students who are immigrants or refugees are common in the halls of public schools in Minneapolis; Imperial County, Calif.; and Chatham County, N.C. The Midwestern city of Minneapolis has seen an influx of mostly Somali refugees and some Mexican immigrants. Imperial County, on the U.S. border with Mexico, and rural Chatham County, near Chapel Hill, have both attracted many Mexican immigrants.
These three very different communities participated in Caring Across Communities: Addressing Mental Health Needs of Diverse Children and Youth, a Robert Wood Johnson Foundation (RWJF) national program that brought school-connected mental health and, in most cases, supportive services to immigrants and refugees at 15 sites in eight states from 2007 until 2010. Each of these program sites has sustained at least soime of this work since the program ended by building strong partnerships and finding creative ways to fund services.
Leveraging RWJF Support and Building Strong Partnerships Sustains Work in Minneapolis. In the mid-2000s, before Caring Across Communities started, Minneapolis Public Schools, Hennepin County, and community mental health providers worked together to bring mental health services to seven schools. Each school had a full-time licensed mental health professional, employed by a local mental health provider, who assessed students and provided individual, family, and group therapy. The mental health professional also worked with teachers and other school staff, consulting on individual students, providing training, and making presentations.
Under Caring Across Communities, the partners focused on learning how to engage and work effectively with refugee and immigrant families in three elementary schools. This work included partnering with a mental health collective called African Aid and La Familia Guidance Center to provide bilingual, bicultural social workers and psychologists who acted as cultural brokers while also providing early intervention and treatment services. Cultural brokers are bilingual and bicultural, know the local refugee or immigrant community, and can spend time with families, conduct home visits, and respond to emergencies. These brokers helped build relationships with both the Somali and Mexican communities to increase trust and decrease stigma associated with mental health services.
Expanding School-Based Mental Health Services. School-based mental health services expanded to 15 Minneapolis Public Schools during Caring Across Communities. "Having a grant from the Robert Wood Johnson Foundation gave us tremendous credibility, and got stakeholders at higher levels engaged at a deeper level than before," said Project Director Mark Sander, PsyD, LP, a senior clinical psychologist for Hennepin County who serves as the mental health coordinator for Minneapolis Public Schools.
The strong relationships that developed during Caring Across Communities enabled project staff to create and sell a sustainability plan designed to attract funds to continue and expand the work. Now Medicaid and several health plans fund mental health services for insured children, while Hennepin County funds these services for uninsured children.
Some health plans are paying an enhanced reimbursement rate that covers some of the costs of providing treatment-related support services, such as consultation with teachers and student support staff and care coordination. Sander says that Caring Across Communities provided support and technical assistance that was critical in securing enhanced reimbursements from some health plans and funding from school districts for some of these services.
Developing a well-defined, school-based mental health program—and strong collaboration between the Minneapolis Public Schools, Hennepin County, local mental health providers, and health plans—was key to sustaining work started under Caring Across Communities. "Our partnerships have been absolutely critical," said Sander, who noted that each partner spent a lot of time early on learning about the goals of the other partners, and about how they did business to be able to partner more effectively.
State Funding Lets Imperial County Continue Work with Parents. Proyecto Puentes, the Caring Across Communities project in Imperial County, Calif., created bridges so immigrant families from Mexico with children at either of two middle schools could learn how to prevent mental health problems and tap into mental health services. The project built on an existing Imperial County Office of Education program in which student assistant representatives work with at-risk students, facilitating support groups, making classroom presentations, and giving referrals to school services and outside agencies.
The student assistant representatives have neither credentials nor authorization to counsel people; they are community residents that a credentialed school counselor at the Imperial County Office of Education trains and supervises. The counselor also helps the assistant representatives develop strategies to address problems facing specific students.
Under Caring Across Communities, the student assistant representatives at the two participating schools worked on building stronger relationships with families through a parent group and student support groups, made classroom presentations to raise awareness of mental health challenges, and provided case management services. The goal was to prevent many mental health problems and reduce barriers to gaining access to mental health services, when needed.
Using a State Contract to Nurture Parents. Although the specific services provided under Caring Across Communities ended with the grant funding, the Imperial County Office of Education is now running the Nurturing Parenting Program, which also focuses on preventing mental health problems. It is offered primarily at schools throughout the county.
The Office of Education has a contract to deliver the program, funded through California's Mental Health Services Act of 2004. "It's unique for us to get a contract like this," said George Miranda, a program manager for the office, and director of Caring Across Communities in the county. "Imperial County Behavioral Health would normally just hire their own people. But they thought the work we did through Proyecto Puentes was great."
The aim of the Nurturing Parenting Program is to build parents' skills and prevent child abuse and neglect in families receiving social services. The program includes three groups:
At the beginning of each session, children meet with one facilitator and parents meet with another for a lesson and related activities. Children and parents then come together for a joint discussion and activities. For example, in the program for adolescents and their parents, one lesson focuses on parent and teen communications. Parents and adolescents complete a Parent and Teens Communication Survey separately and then come together to discuss their responses. Areas where their responses are different can lead to conflict. The facilitator encourages parents and adolescents to use what they learned from the survey to improve communication with each other.
The weekly program ranges from 12 weeks for adolescents to 16 weeks for children under age 5. "It's a very powerful program," said Miranda.
Building Strong Relationships and Listening to School Partners Lets Services Continue in Chatham County. Creating Confianza (trust) relied on a partnership among a middle school, a high school, a bilingual/bicultural mental health center (El Futuro), and the University of North Carolina School of Social Work to help immigrant students get more mental health support. Like Proyecto Puentes, this Caring Across Communities project worked with Mexican immigrants. As with the Minneapolis Public Schools' project, billing for services was a key part of the strategy to continue providing services after grant funding ended.
A bilingual/bicultural licensed clinical social worker from El Futuro spent time at each school during Caring Across Communities, assessing children and referring those who needed help to the El Futuro clinic. She also ran workshops designed to teach parents about typical adolescent development and help them understand mental health challenges.
Focusing on Middle School Students and Teacher Training. After Caring Across Communities ended, project staff decided to focus on the middle school. "If kids don't do well in eighth grade, they're more likely to drop out. We wanted to focus on having middle school students be successful in making that transition," said Mimi Chapman, MSW, PhD, associate professor of social work at the University of North Carolina at Chapel Hill (UNC-CH), and project director for Caring Across Communities in Chatham County. High school students can also get to El Futuro's clinic more easily than middle school students, and middle school leaders were very supportive of the program.
A licensed clinical social worker, based at the school two days a week, sees students who need help at El Futuro's office. Medicaid reimbursements cover most of her salary, while Chatham County covers services she provides to uninsured children.
Project staff also trains teachers—an effort originally planned as part of Caring Across Communities that was stopped after an initial training session because schools seemed resistant. By the time the grant ended, however, school administrators had become more supportive of the work and encouraged teacher training. Using a grant from the UNC-CH North Carolina Translational and Clinical Sciences Institute, Chapman developed a training program that uses photography to help teachers understand what life was like in Mexico for their immigrant students, and to teach them about issues related to mental health.
The two-day training, held in August 2011, included a trip to the university's Ackland Art Museum to see "Dreams of the Rich North," a photography exhibit that follows a Mexican girl on her journey to the United States. "It's a way to break through some of the myths and negativity and tap into people's empathy for this population," said Chapman. "It seems like that has to happen before people are willing to be courageous in their teaching."
During the training, a lawyer also talked about why people from Mexico move to North Carolina, and the benefits to which they are entitled.
Chapman attributes the continuation of work done under Caring Across Communities at the middle school and the new teacher training to the strong relationships forged during the program, and efforts to strike a balance between what project planners set out to do and what the schools were ready for. "If we had really pushed teacher training earlier, I think we would have alienated everyone. They needed to get to know the idea bit by bit and see the benefits of it," she said.
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