Flexible Tier 2 Mental Health Interventions:

Offsetting the Emotional and Financial Costs of ER Visits & Higher Levels of Care

By Lucille Carr-Kaffashan, PhD and Jerry Barone, ESS Chief Clinical Officer

The pressure to return American students to the classroom safely and swiftly is high. Academic setbacks are bad enough, but the impact of pandemic-related school closures and remote learning on students’ mental health and well-being has reached crisis proportions. School districts are gearing up as never before to offer school-based mental health services to accommodate the anticipated groundswell of students who may be struggling with various trauma responses triggered by the pandemic.

The Scope of the Problem

Pediatricians, educators, and mental health professionals had noted rising mental health concerns in K-12 students for at least 10 years before the COVID-19 crisis emerged. According to the National Alliance on Mental Illness (NAMI), 1 in 5 students ages 13–18 had a diagnosable mental illness prior to the global pandemic, and current research is showing that mental health problems and the demand for services have dramatically increased since the spring of 2020. According to an analysis by FAIR Health, the demand for adolescent mental health care surged last year even though the overall need for adolescent healthcare declined. Compared to 2019, mental health care claims for children 13–18 doubled in March and April of last year, while the number of overall claims for this age group was about half, and that trend continued for much of the year.

The FAIR Health analysis also revealed that the percentage of all medical claims “for intentional self-harm nearly doubled in March and April, compared to the same months in 2019. Claim lines for overdoses increased by 94.91% in March and 119.31% in April compared to the year before… and both remained elevated through November.” The analysis found that the most common diagnoses in teenagers were major depressive disorder, generalized anxiety disorder, and adjustment disorders.

The above findings are consistent with the CDC’s report of “a 24% spike over last year in emergency visits for mental health issues among 5-to-11-year-olds, and a 31% rise among 12-to-17-year-olds.” Harvard researchers found that “caregiver-reported depression, anxiety, and misbehavior among American kids in the general population … have reached levels typically seen only in those previously diagnosed with a form of mental disorder.”

Following a year of disruption, isolation, and unrelenting stress, re-entry to an in-person learning environment will be challenging for many students. The number of previously undiagnosed students who will exhibit mild to moderate mental health challenges is likely to sharply increase, taxing the existing clinical resources of districts well into the foreseeable future. For these reasons, Effective School Solutions (ESS), a longtime specialist in providing intensive Tier 3 services, has turned its attention to helping schools build or enhance flexible Tier 2 levels of support.

Watershed Moments in the Development of Tiered Models of Mental Health Care

Over the last 60 years, there have been two watershed moments that have advanced a tiered model for the delivery of mental health care. The first was the signing of The Community Mental Health Centers Act by President John F. Kennedy in 1963. This legislation created federally funded community mental health centers that were mandated to provide multiple levels of care, allowing individuals to receive services within the least restrictive environment, within their own communities. The creation of community-based outpatient care available on a sliding scale, along with the development of highly effective medications to treat mental illness, brought an end to the warehousing of patients in mental hospitals, and the long or permanent confinements that separated individuals from their communities.

The second watershed moment occurred in the 1980’s when managed care became ubiquitous. Managed care arose within the context of double-digit inflation in the cost of medical care in the United States. Its purpose was to address waste and overutilization of services, to curb spiraling health care costs, and to improve a fragmented delivery system. When considering these lofty goals, managed care can hardly be declared a glowing success. But it did create the economic necessity that pushed mental health and substance abuse services into an expanded continuum of care, popularizing partial hospital and intensive outpatient programs as alternatives to either inpatient or traditional once-per-week outpatient care, neither of which might be the right intensity for any given individual at any given time. As a result, there are now many more treatment choices to match the required intensity of care, and the preferred service location, based on a patient’s needs at any given moment.

School-Based Mental Health Services — The Next Watershed Moment

Over recent years, especially since the surge in child and adolescent mental health concerns, and in light of increased fears regarding school safety, schools have moved steadily in the direction of providing onsite mental health services for students. Perhaps, in years to come, the COVID-19 pandemic will be recognized as the tipping point that brought schools fully into their own as the preferred site for the delivery of most behavioral health (mental health and substance abuse) services for children and adolescents.

Schools are an obvious and sensible choice as primary hubs for the delivery of student behavioral health care. Children typically spend 6 or more hours per day in school, and even in rural or remote areas where healthcare providers and systems are limited, there are typically always schools. School environments provide the perfect setting within which to observe and intervene with the whole child: academic achievement, self-regulation, social functioning, and physical health and development can all be monitored and addressed. Even more importantly, schools may be viewed by some families as less threatening, more accessible, and more “normal” than hospitals or healthcare facilities, thereby reducing some of the barriers to seeking mental health treatment.

From Anxiety or Depression to the ER, to the Hospital — A Stressful and Often Unnecessary Journey

The first mental health intervention for many children is often in the ER or an inpatient setting. Among the causes for this are the stigma associated with seeking mental health services that sadly still exists, a lack of awareness about mental health problems, the lack of comprehensive service delivery systems in many parts of the country, and potentially prohibitive costs for outpatient care. And, unfortunately, no matter how caring and competent the staff, ER visits and inpatient stays are rarely benign events for children or their parents. More often, they are frightening and off-putting, perhaps even making it less likely that families will follow-up with much needed outpatient mental health services in the future.

This direct path to more intensive levels of care has been exacerbated by teachers and other school professionals not having the opportunity to directly observe their students due to remote learning environments. This disconnect has created a vacuum in which students’ symptoms have become silent. Without the watchful eyes of teachers, fewer student problems are being flagged for early interventions that might offset the need for higher levels of care. Parents are not alerted, referrals for assessment are not made, and parents wait too long, leading to an increase in ER visits. The time between symptom recognition and referral has been elongated, with a corresponding increase in symptom acuity.

A Service Delivery Model That Works: Multi-Tiered Systems of Support (MTSS)

One significant reason why the expansion of school-based services may signal the next watershed moment in the delivery of behavioral health services is that many districts have already adopted a MTSS framework. Inherent in the MTSS model are tiered services that span everything from prevention services and awareness, all the way up to intensive treatment for the most fragile of students. ESS has long been a proponent of MTSS, and has created a well-tested, highly effective model for delivering Tier 3 services within a school district that in many cases can help avert potentially unnecessary out-of-district placements.

Tier 3 services are designed for the most vulnerable students, and typically include at a minimum the following components: individual psychotherapy, process and/or psycho-educational groups, educational support, clinician-teacher collaboration, family/caregiver consultation and support, the capacity for ongoing risk assessment, and coordination with medication prescribers and other community services. Tier 2 services are for students with mild to moderate symptoms and can include short-term individual and/or group counseling for students, caregiver education/support/consultation groups, educational supports, and referral/coordination with community providers. Tier 1 services are designed to ensure mental health awareness and education throughout the school community. Prominent within Tier 1 should be professional development opportunities for teachers to build skills and confidence in educating students with mental health challenges, to cultivate a trauma-attuned perspective, and to develop the capacity to teach social-emotional (SEL) skills. Tier 1 services should also include a robust SEL curriculum across all grade levels, a universal screening tool/methodology for all students, mental health education/promotion activities for caregivers, and wellness services for all employees.

To assist districts with the challenge of school re-entry, ESS has developed a new Tier 2 mental health support service called Flexible Therapeutic Re-entry Support. As part of this menu of services, ESS can place one or more full-time, licensed and highly skilled mental health clinicians onsite who can offer a range of clinical and consultation services based on a district’s needs and priorities. An ESS Flexible Therapeutic Re-entry Team can work across multiple schools to:

• Conduct assessments and make referrals for students who may require mental health support and counseling, including specialty areas of intervention, such as school avoidance and substance abuse issues.

• Provide direct clinical treatment to students exhibiting mild to moderate mental health challenges, carrying a concurrent caseload of up to 12–15 students, most often supporting students in 6–8 week increments of care (up to 48–60 students can be supported annually with this model).

• Intervene with students who are exhibiting episodic school avoidance and school refusal upon re-entry.

• Provide job-embedded professional development sessions and individualized coaching for teachers to help them build new skills for working with traumatized students, and to sharpen their ability to identify mental health warning signs.

• Design and conduct, or support already existing, community awareness and parent education sessions to help ensure that all stakeholders in the community can work in concert to foster student social-emotional health.

• Provide expert mental health guidance and resources to district re-opening committees.

Armed with evidence based ESS protocols, plus their own well-honed skill sets, ESS clinicians who are part of a Flexible Therapeutic Re-entry Team can offer a wide array of services customized to a district’s needs. They can also ensure that the menu of services delivered by the Team will be refined and adapted over the course of the school year, as the needs and priorities of students and educators change.

Services can also be adapted as funding opportunities shift. In December 2020, and then again in March 2021, the federal government authorized COVID-19 relief funding for distribution to K-12 districts to assist with the re-opening of schools. The enhancement of mental health services is an approved use for this funding. Numerous states, including New Jersey, have also provided supplemental allocations for school districts to assist with re-opening, and shoring up mental health support is an approved use of this funding as well.

Experts agree that the pandemic has exacerbated the mental health crisis that has been affecting the lives of American students and their families over the last decade. Schools have been bearing the brunt of this crisis, as school professionals have been charged with educating increasingly distressed and dysregulated youngsters. It appears, however, that schools can also offer the most hope, as hubs for transformational mental health systems of care.


Exclusive: Teenagers’ mental health claims doubled last spring

Children’s Mental Health: Improving Access to Care

School-Based Mental Health Services: Improving Student Learning and Well-Being

Making the Case for a Comprehensive Children’s Crisis Continuum of Care

Reinventing K-12 Mental Health Care. Effective School Solution partners with school districts to help develop K-12 whole-school mental health programs.

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