While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
As a result of civil war in Liberia, after surviving trauma most Americans cannot even imagine, about 200 refugees from the African nation settled in Bucks County, Pa. One family, for example, while scavenging for food, had seen dead people lying in the streets. Some children had spent years living in refugee camps before coming to the United States, often with adults who were not their parents and sometimes were not even relatives. Many had little or no formal education.
The School Outreach Program, started under Caring Across Communities: Addressing Mental Health Needs of Diverse Children and Youth, offers school-based mental health services and case management support to Liberian refugees, along with a few Hispanic and Turkish immigrants, at Franklin Delano Roosevelt Middle School in Bristol Borough. The Robert Wood Johnson Foundation (RWJF) national program brought school-linked mental health services—and usually connections to various social services—to immigrants and refugees in Bucks County and at 14 other sites from 2007 through 2010.
Partners in the School Outreach Program—Family Service Association of Bucks County, Bristol Township School District, and the Bucks County Behavioral Health System (the county's Medicaid agency)—designed a program geared to families most in need of help. Services included individual, family, and group counseling, with a focus on family counseling in students' homes. The partners hired a part-time African-American clinical social worker and a Liberian case manager to work with the families.
Getting in the Door. The first step in helping the Liberian students and their families was gaining their trust and addressing the stigma they attached to mental health services. The Liberian members of the program’s advisory committee—which included church leaders, parents, school district staff, and mental health professionals—had taught the other members about the issue of stigma around mental health. This turned out to be a very important lesson.
"We never mentioned mental health, which the Liberian advisory committee told us would make people run away. We were just there to work with the family and to help the child do better in school," said Audrey J. Tucker, LSW, chief executive officer at Family Service Association, and project director for Caring Across Communities in Bucks County.
Religion is extremely important in the Liberian community—which was another important lesson in working with this group. Project staff worked closely with a Liberian minister on the advisory committee, often attending his church and the three other Liberian churches in the Bristol Township School District. With the help of the advisory committee, staff also organized a Family Community Day at a soccer tournament that included exhibits on mental health and other services from 22 agencies and providers.
Case management services—connecting families to a food bank, better housing, and legal services—were another way to get in the door. "They learned to trust us, and then they would open up and we could help them," said Tucker. The links case management provided to social services also reduced the stress the families were living under, enabling them to function better.
Improving School and Home Life. Once the Liberian community began to accept the School Outreach Program, the clinical social worker and the case manager were able to help 62 students and more than 90 family members. The social worker and case manager made 345 counseling visits and 375 case management visits—most to students' homes.
The program also included two training sessions for teachers, counselors, and principals, and local mental health and human service providers on how to help students who had experienced trauma. The social worker and case manager also met with teachers and other school staff regularly to discuss the program and ways to help students.
Students who participated in the School Outreach Program performed better in school and related better with family members. Attendance improved 81 percent among students who had attendance problems before they received help. School discipline problems fell by 69 percent, and suspensions dropped by 75 percent. Symptoms of depression (e.g., inability or decreased ability to experience joy, difficulty making and keeping close relationships, and lack of motivation or inability to complete tasks) declined by 48 percent, as measured by the Children's Depression Inventory.
As some of the children served by the School Outreach Program moved up to Truman High School during the last year of the RWJF grant, project staff worked with the school district to also offer the program there.
Sustaining and Expanding the Work. The strong partnership between Family Service Association, Bristol Township School District, and the Bucks County Behavioral Health System built during Caring Across Communities paved the way for efforts to continue and expand the work after the three-year grant ended.
With the help of the Behavioral Health System, Family Service Association has established state-licensed behavioral health treatment sites at Franklin Delano Roosevelt Middle School and Truman High School. The agency can bill Medicaid for clinical services at those satellite sites. The Bucks County Children and Youth Social Services Agency is funding home visits and case management services, which Medicaid does not cover.
The satellite sites serve many of the students and families that the School Outreach Program served, along with any other students who need help. Students covered by insurance other than Medicaid receive referrals to Family Service Association’s regular outpatient behavioral health program or to another provider.
Through the work done during Caring Across Communities and at the satellite sites at the two schools, the Behavioral Health System has adopted the model, establishing treatment sites at 17, mostly elementary, schools (as of August 2011). Family Service Association runs 12 of these sites. "Every year we are adding more schools to the Bucks County community. Consequently, children and families are able to access mental health services in their local schools. It’s all because of Caring Across Communities," said Tucker.
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