Rx for School Success
The Center for School Success and Alice Peck Day Hospital have initiated Rx for School Success, a project to proactively address the health and learning needs of school-aged children (ages 5-18). The project includes the development of a screening tool, training for clinicians on how to use the tool and interpret the findings, and a team intervention delivery model that involves collaboration among all the key stakeholders (student, family, educators, physician/clinician) who can support a student’s academic achievement.
We need to do a better job of weaving a safety net of understanding,
appreciation, and guidance in the family, in the community and school.
We need to start thinking of health and education as interlocking spheres.
Everett Koop, MD
Former U.S. Surgeon General
Learning happens differently for different children. While school is designed for some children’s kind of minds (e.g., those with strengths in attention, memory, language, social skills), for others, it is a daily struggle. Unfortunately, the educational system rarely accounts for this variability. Regardless, at some point during their school years, most children experience challenges with their learning. When this happens, it can often make them wonder if they are smart or not. The more children worry, the harder it is for them to feel good. Children who have certain protective factors in their lives are more likely to bounce back if school work seems too difficult. They are also more likely to have hope for the future. Children that do not have many protective factors often give up. They can also find themselves physically and emotionally worn out. Sometimes they turn to people and things that are not healthy for them.
Recent research suggests that positive learning experiences are regularly not accessible to 35-40% of children. Studies from multiple fields indicate that the impact of “differences in learning” on society may be much broader and deeper than previously realized, affecting not only children’s ability to succeed in school, but their overall health and well-being.
Alice Peck Day Memorial Hospital
The primary care providers of Alice Peck Day Memorial Hospital (APD) see over 3000 children (ages 5-18) annually. Of those children, roughly 25% fall within the 35-40% statistic mentioned above and are already diagnosed with attention weaknesses, anxiety, depression and/or substance abuse. In addition, according to APD providers, there are likely another 10-15% of their patients whose learning difficulties are not being addressed as they do not meet the criteria for special education services, or they have yet to be diagnosed.
As the health and learning needs of school-aged children have become ever more complex, so have the demands placed on the physicians and educators who work with them increased. Regrettably, tools, training and technical assistance lag behind societal demands and the capacity of these professionals to manage heightened expectations independently has been exceeded.
This reality is mirrored in consistent findings published by the American Academy of Pediatrics — that is, parents frequently look to their child’s physician for help, guidance and advice on their child’s school-related concerns. Consequently, pediatric office visits for well-child check-ups, and acute or somatic complaints (e.g., headache, stomach ache, depression, anxiety) are often used as the “gateway” for parents to bring up psycho-social and/or behavioral matters that are negatively affecting their child’s school performance. Primary care providers at APD report being all too familiar with serving in this role. They note that parents’ questions span both health and learning topics and may be related to the child’s academic progress, the child’s ability to attend and concentrate, or the child’s level of competence to interact and respond appropriately at school.
In general, however, pediatricians rarely know how best to respond to non-medically oriented requests due to lack of training and experience and/or unfamiliarity with referral resources. Additional barriers to supporting patients’ school-related concerns include time and reimbursement issues, communicating with teachers, and navigating parent/school conflicts. The mental/behavioral health needs of students are also seen as barriers to supporting them. These challenges are reflected in a national survey where only 16% of pediatricians felt competent to address school-related issues, while only 6% of families reported they were satisfied with their pediatrician’s response to these concerns.
As you can see, the presumed expectations that pediatricians and family physicians must deal with, illustrate why no single discipline is able to adequately address all of the conditions that may negatively influence educational and/or health disparities. Therefore, consideration should be given to collaborative, community-based models that take into account the explicitly linked fields of health and learning.
Due to the ever-changing nature of health care delivery, APD is currently focusing its efforts on promoting programs and services that address better managed care and population health. As such, APD is committed to exploring partnerships that can build its capacity to foster the well-being of its patients and the community at large in a cost-effective manner.
Center for School Success
For the past twelve years the Center for School Success (CSS) has worked diligently toward its mission to help struggling students achieve measurable success in school and beyond. At no time in life are we expected to expose our weaknesses more publicly than during the school years. Learning difficulties can be experienced at any age because the expectations of school change over time. In addition, children can spend years hiding their learning challenges in fear of not living up to the real or perceived expectations of their parents and teachers (or even themselves), which consequently manifests through a range of bio-psycho-social-emotional issues.
For example, Brian seemed to have a natural aptitude for math, but now, towards the end of middle school, his inability to memorize basic math facts and rules has affected his grades; he is beginning to wonder if he is just plain stupid. Sasha studies diligently and can explain everything she has learned, but freezes up when a test is put in front of her. She spends many test days absent from school. Kevin can’t sit still in class and he always seems to be tinkering with something. If you put a broken mechanical device, like a radio or car part in front of him, he can fix it effortlessly. He is just biding his time in school, so he can graduate and work in his uncle’s garage business.
Through CSS’ innovative student learning assessments and work with thousands of educators, we have identified key learning trends that are the most likely to negatively impact a student’s performance at different times in his/her school career. These trends have been corroborated by a large-scale National Institutes of Health study on the reciprocal nature of health and learning. The CSS trends were included in questionnaires completed by students and parents, and were endorsed by both respondents as significant influences. We have also determined protective factors that can help ease learning challenges.
CSS is now poised to expand our experience and expertise. We plan to broaden our scope and incorporate all we have learned to build a community-based model that includes primary care providers, educators and families. APD has presented us with the opportunity, avenue and relevant child population to pool our resources and pilot our efforts. We are excited to be working with such a respected, committed and collaborative partner.
Center for School Success and Alice Peck Day Hospital Partnership
Rx for School Success is a preventative model that will build the capacity of families, educators and health care providers to work collaboratively and cost-effectively to address the inter-related health and learning needs of children ages 5-18.
Rx for School Success integrates the following key elements that are important for health care providers and educators in order to better serve school-aged children:
- Access to necessary tools to be able to efficiently and effectively identify potential school-related concerns;
- A broader knowledge base to identify the relationship between variations in learning and psycho-social/health problems;
- An understanding of how these types of issues can best be addressed; and
- Coordinated supports/resources to be able to work together with all those who are involved with supporting a child’s health and learning.
CSS and APD have purposefully structured Rx for School Success into three incremental phases to ensure the integrity of each component of the model: Phase 1: screener development; Phase 2: clinician training; and Phase 3: project pilot (july 2016-June 2017).
Pilot Project Components
Health and Learning Screener
The most successful and cost-effective way to reduce health and learning problems, is to prevent them from developing in the first place. For over fifteen years the American Academy of Pediatrics has issued Policy Statements emphasizing the importance of psycho-social aspects of pediatric care and the role of the pediatrician in educational planning. Well-child visits are an opportune time to screen for school-related issues; acute visits for somatic complaints are also prime opportunities to explore the principal contributors to such problems.
CSS and APD have developed a health and learning screener that measures risk and protective factors related to optimal health and learning outcomes. The brief, easy-to-administer screener ultimately will be given during well-child and or acute visits to all APD patients. For now, it will be offered to the identified children who either are currently diagnosed with a health/learning problem, or those who the pediatricians have identified as “at risk”. Responses to items on the screening tool are scored and results are available to the provider during the visit. Any “red flag” areas are evident.
In the long-term (after the pilot phase), CSS anticipates that the screener will be offered to all children at their annual well-child visits. Over time, the children will develop a health and learning profile from which physicians can track any changes (positive or negative). When a screener is administered at yearly visits, a pattern of strengths and ongoing challenges can be discerned and any sudden incremental change can be quickly addressed.
CSS developed and delivered training for participating clinicians which included information they will need to understand typical learning breakdowns for children ages 5-18, as well as how to interpret the screener. The training will increase health providers’ clinical acumen regarding the detection, intervention and prevention of common-school related concerns. The training will also include effective ways to communicate risk and protective factors to families and to work collaboratively with the Rx for School Success team of professionals (care manager, learning specialist, behavioral/health specialist) on behalf of the child.
During the pilot phase, CSS will serve as a collaborative team member working with APD’s pediatric health care providers to deliver a more holistic approach to addressing the school-related challenges that may present during well-child and acute office visits. CSS learning specialists will work on-site several days a weeks, as will designated behavioral/health providers, to serve as resources and intervention specialists working as a team, including the other specialist(s) and the primary care provider. The team also includes a care manager who will serve as the point person to coordinate any actions that need to be taken/communicated.
As a pilot effort, designated APD primary care providers will gain the knowledge and skills to use the screener to facilitate school-age problems during well-child and other office visits. If the screener results flag areas related to learning or behavioral/health issues, the provider will share the information with other team members to further explore root causes and/or develop an intervention action plan. The team intervention approach provides a structured means to offer valuable support and resources to the provider and to promote better managed care overall for the child and his/her family.
Once piloted with the APD pediatric population, CSS and APD will determine the most promising and effective aspects in order to scale the model and offer it to other interested Upper Valley primary care providers to use in their own practices.
Measuring Pilot Outcomes
The Institute of Health Care Improvement in Cambridge, MA has developed Triple Aim, a well-documented framework that includes three dimensions: better care, better health and reduced costs. Triple Aim initiative outcomes have shown that, to do effective work, it is important to: harness a range of community determinants of health (this will occur during Phase 1); empower individuals and families; and substantially broaden the role and impact of primary care and other community-based services (school/behavioral health) (Phase 2-3).
Additionally, Triple Aim suggests that in addressing these dimensions, collaborators (such as CSS and APD) need to: identify target populations; define aims and measures; develop a multi-faceted approach; and implement a scaled-up model that is adaptive to local needs and conditions. CSS and APD have included these components in Rx for School Success.
Watch an April 2017 presentation by the Rx for School Success Team on the Impact of Learning on Health