RECOMMENDATIONS TO LOS ANGELES COUNTY FOR BUILDING
THE INTEGRATED ISHC MODEL
Submitted by LA Health Action
September, 2009
The convergence of opportunities to leverage local funding to address prevention and
early intervention for children and youth and add new wellness centers at LAUSD
schools has brought committed leadership together. Despite budget challenges and
the uncertainties of national and state health care reform, the discussions have resulted
in a movement to improve school communities’ health through designing a robust
Integrated School Health Centers, (ISHCs)s. Building upon decades of school and
primary care leadership to provide prevention and early intervention services, this model
proposes integrating health, behavioral and public health with school health programs.
Below you will find a vision and set of recommendations to Los Angeles County (LAC)
designed to create a Los Angeles Model for School Health delivered through Integrated
School Health Centers (ISHC). Although Los Angeles County operates and funds a
large health care and public health infrastructure, it has not yet adopted improving
school communities’ health as a major priority. This document seeks to further that goal
and offer a template to design and implement it.
ISHCs would be piloted in response to the April 2009 Board of Supervisors motion but it
is intended that the ISHC would become the desired model for all school based and
school linked health centers. The concept focuses on an ideal ISHC model that is
integrated into school activities and structure, partners with Public Health, Department
of Health Services and Mental Health and other agencies and brings a system of care to
the school community. Ideally ISHCs will some day become Wellness Centers serving
an entire school community and include youth development and services for the entire
family. Not all the resources exist today to implement this vision and sustain the
proposed LA Model. ISHC model incorporates many of the desired reform components
being discussed at the federal and state level. Our local efforts are expected to
demonstrate how public systems can cooperate to improve school communities’ health
and build on the existing school based and school linked health centers that operate in
Los Angeles County.
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CREATING A COUNTYWIDE VISION FOR IMPROVING SCHOOL
HEALTH IN LOS ANGELES COUNTY
VISION STATEMENT
Adopted – June 2, 2009
Through a strong, effective and sustainable countywide partnership, we want to improve
the health status and academic performance of all students by expanding access to
high quality integrated health services as part of the health care and education system
that will:
1.
Expand the range of health and wellness services and school health centers
to include appropriate medical, dental and integrated behavioral health
services, early access to wellness services and social supports, based on
needs of students and the communities they live in.
2.
Engage students, parents, faculty, administration and the community in data
driven planning processes and sustaining health and wellness services and
school health centers in an atmosphere of learning and collaboration.
3.
Leverage county, school district, state and federal funding and resources to
build public and private support for school health and wellness services.
4.
Build healthy environments at schools through a variety of strategies that
optimize opportunities for physical activity and good nutrition, integrate
systems of obesity prevention, mental health and health promotion, and
actively link students and families to community resources.
5.
Offer an entry point to early pipeline opportunities for students into health
professions.
6.
Create an effective, meaningful and strong coalition structure by engaging
key systems and departments to participate in system design and
coordination, program implementation and policy setting.
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RECOMMENDATIONS TO LOS ANGELES COUNTY FOR CREATING
AN LA MODEL FOR INTEGRATED SCHOOL HEALTH CENTERS
Create LAC Infrastructure to Lead and Support ISHC
 CEO assume role as LAC School Health Leader and direct each relevant County
Department to appoint a liaison for school health who will take responsibility for
systems integration, problem solving and being a transformational leader.
o Involve Departments of Children and Family Services, Health Services,
Mental Health, and Public Health, Office of Drug and Alcohol Programs,
LACOE, juvenile justice at minimum
 CEO appoint Directors of School Health and Behavioral Health to work with ISHCs
pilots and schools to improve clinical practice and to address policy and operational
barriers and. These Directors shall:
o Champion ISHCs as core DHS and DMH strategies to improve the well-being
of children and youth as well as liaison with other County Departments
o Assign a pediatrician and a psychiatrist to partner in the development, and
leadership of a QI initiative
o Assign a consulting psychiatrist to ISHC pilots to provide clinical consultation
and case conferencing support
o Offer trainings geared toward pediatric clinical practice and advance the skills
of school health personnel in recognizing primary care, PH and BH issues
early, coordinate care and intervene with effective school based primary care,
PH and BH strategies
o Create pathways to LACDHS and LACDMH services for families needing
services beyond ISHCs’ scope of practice
o Assist with referrals for students needing higher levels of care when referral
processes are not working properly.
 House the ISHC pilot in an LAC Department that will take responsibility for leading
and championing school health and incorporating the role of ISHCs into LAC’s
strategic plan.
 Convene a policy and operations advisory group that includes LACOE, the LA Trust
for Children’s Health (LA Trust), LAUSD, other districts, LA SBHC Coalition and key
stakeholders, including parents and students to provide ongoing problem solving
and policy direction for ISHCs in LAC. The CEO shall:
o Establish and convene the policy advisory group. Develop and prioritize
agenda issues related to governance, membership, developing finance
demonstration projects, interface with other LAC planning efforts, relationship
with other organizations and timeline for activities
o Identify local champions and involve them in sustainability and policy issues
o Convene school leadership forum annually to orient them to school health
and mental health issues
o Assure the voice of the consumer in program and policy development
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Execute an MOU with LAUSD and other school districts, over time, to formalize
LAC’s leadership, regulatory, and monitoring role, AND the partnership for policy
development and problem solving across agencies.
Build a Sustainable Model
Operations
 Assess school readiness to implement ISHCs standards
o Consider utilizing “Survey of Characteristics and Funding of School Mental
Health Services School Health Questionnaire” to determine appropriate sites
for ISHCs
o Require selected schools identify key teachers and administrators to be
trained and implement classroom management prevention strategies
 Adopt a Quality Improvement Initiative to improve student health
o Obesity, depression/suicide prevention and/or other PH indicators
o Adopt standardized tools and common definitions of expected outcomes
o Utilize key experts and strategies to help IBHCs meet goals
 Create an ISHC Learning Community to spread best practices and learnings
o Led by the LA SBHC Coalition to assure the adoption of common policies and
procedures, spread lessons learned and provide TA.
o Involve LAUSD and the LA Trust to assure consistent policy and practice
development.
o Conduct the QI Initiative activities as a joint project of the Learning
Community
o LAC monitor ISHCs pilots to assure fidelity to the ISHCs model. Findings
reported through the QI/LC processes to modify practice, policy and
standards as indicated
 Set Policy and Practice by Building Upon the Work of National and State SBHC
Associations
o National interdisciplinary collaboration policy
o National interdisciplinary practice position statement
o California draft guidelines
o California draft standards
 Become a member of California School Based Health Center and the National
Assembly of School Based Health Centers
 Commit to an ongoing system of professional development, skills building technical
assistance and cross training for providers
 Align effort with future EHR planning and HIT implementation
 LAC monitor pilot ISHCs to the standards adopted.
Financing
 Create a stable funding stream by providing County funded core operations grants,
access to contracts administered by various County departments and insure ISHCs
maximize FFS revenue by maintaining relevant public and low cost insurance
contracts
o Examine county department funding streams to identify potential contract
sources for ISHCs.
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o Identify the ISHCs pilots as strategic partners within the LAC family of
activities
o Utilize FQHC model that allows for enhanced Medi-Cal revenue
o Engage Medi-Cal/Healthy Families health plans to ensure and improve billing
and revenue for assigned and unassigned students and family members
o Provide EPSDT, 3632 and other appropriate DMH contracts to fund a
continuum of MH services
Build Upon MHSA PEI Planning
o Consider the MHSAOC identified 18 programs for students at risk of school
failure
o Adopt programs that have demonstrated success in LAUSD and that are a fit
to individual schools where ISHC will be located
Utilize MHSA Innovation funding to build and test new approaches to improving
school mental health services:
o DMH review NM’s Mental Health Advocates’ model as a strategy to improve
mental health across multiple additional school districts and implement
appropriate strategies
o Develop strategies to standardize the delivery of mental health services
across the continuum of pilot and future ISHCs
Engage Alcohol and Drug Program Administration analyze how its programs could
be modified and integrated into pilot sites
Work with Alameda County, State of California and others to leverage federal funds
o Examine the use of school district, Public Health, DHS and DMH funding
streams to determine potential funds for additional federal match
o Modify the MAA claiming plan as appropriate to incorporate ISHCs and their
parent FQHC in LAC’s plan
Seek State and federal grants to improve the ISHC delivery system
Engage local foundations to participate in policy, planning and funding innovation
Recommend 3 of the ISHCs pilots be located in the TCE LAC place based project
areas—Boyle Heights, South LA and Long Beach
Analyze and Report on School Health and the Role of the Pilot ISHCs
 Summarize the student health assessment and health registry information annually
and report trends over time
 Design and implement a QI initiative that supports school district priorities and
address key primary care, public health, dental, and behavioral health indicators.
Partner with LAUSD, LA Trust and other districts, in the future, to design and
implement QI initiative to assure consistency with district priorities and standards.
 Disseminate QI Initiative findings broadly to school districts and other SBHCs
 Commit to an ISHC pilot program evaluation and define parameters at start up
 Create advocacy and communication strategies to inform key policy makers about
the benefits and challenges in improving school health
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Build Upon Other States/Regions’ Successful Models—Some Suggestions for
Consideration
 Clinical Fusion software developed in Colorado and used by Maine’s Children’s
Hospital to provide a range of support and integration of information for the following:
student registration, screening tools, phone & email follow up on FAQs, group
training, risk questionnaires, provider logs, contact templates, ticklers and reports
 Envision New Mexico, a quality improvement partnership led by the Department of
Pediatrics, University of New Mexico with the Department of Health, Human
Services Department, Indian Health Service, New Mexico Alliance on SBHCs. This
partnership conducts multiple strategies for quality improvement and systems
change, training and education, community outreach and telehealth.
 Arapahoe House, a comprehensive behavioral health agency partners with the
SBHCs in Denver to treat students who self identify as having substance abuse
problems and willing to go for treatment. Denver is one of the few SBHC systems
that has successfully incorporated substance abuse.
 Alameda County utilizes an annual survey developed by UCSF of SBHC users to
measure school performance and health issues.
 Maine has adopted Motivational Interviewing as a technique for BH interventions.
This technique is widely used in the field to determine clients’ readiness to change.
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