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
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 8-18). 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.
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 in time (for whatever reason), almost all children “hit a wall” (or face a challenge) which can make them doubt whether they are smart.
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 8-19) 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 thirteen 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 (to which CSS contributed) 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 builds 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 8-19.
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.
Pilot Project Components
CSS developed and delivered training to four APD primary care providers and three Specialists (learning specialist/behavioral health) in May and June 2016. The training offered information and activities to help the clinicians understand the rationale for the program, elements of the two screening measures that were developed for the program and how to score and interpret them, as well as an explanation of typical learning breakdowns for youth ages 8-19. The goal of the training was to begin to increase health providers’ clinical acumen regarding the detection, intervention and prevention of common school-related concerns. The training also included effective ways to communicate risk and protective factors to students and their families and how to work in tandem with the Rx for School Success team of professionals (program coordinator, learning specialist, behavioral/health specialist) on behalf of the child.
Pre-Screener and Health and Learning Questionnaire
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 two assessment tools: a 20 question pre-screener that is administered during well-child visits and an online health and learning questionnaire that measures risk and protective factors related to optimal health and learning outcomes. The pre-screener is completed on a tablet that is currently used for patient registration and other health-related surveys APD makes available to its patients. Responses to items on the screening tool are scored electronically and results are immediately available in the patient’s electronic medical record for the provider to use as a resource during the appointment. Any “red flag” areas will be evident.
Based on a child’s pre-screener responses, s/he will fall under one of three categories: high risk, moderate risk or low risk for learning challenges that might impact health. Those children who fall in the high or moderate range are offered the opportunity to complete a more-lengthy online questionnaire (75 questions) at home after the visit. The health and learning questionnaire measures risk and protective factors related to optimal health and learning outcomes. It typically takes less than 15 minutes to complete.
The results of the questionnaire are discussed between the program coordinator and the child’s health care provider. If the questionnaire results indicate the child would benefit from meeting with an Rx for School Success Specialist (learning specialist or behavioral health specialist) and the child/family meet specific criteria, the child are invited to participate.
- Child’s pre-screener score is high or medium risk; or ADHD check suggests that child would benefit due to longstanding school-related concerns that are affecting his/her health;
- Child is underperforming (not doing as well as s/he should be/capable of); this could mean for example, that the child is getting good grades but may be working much harder than s/he needs to, or anxiety level of maintaining good grades is impacting health;
- Child does not have an existing diagnosis; no IEP or ineffective IEP;
- Child doesn’t qualify for special services (extra help) but may have a 504 Plan;
- Child/family has been informed about the goal of the program: Helps children who are struggling with some aspect of learning (want to do better in school but don’t know how); To help child take more control of his/her learning; To identify child’s learning strengths and weaknesses; To help child understand how s/he learns best;
- Child acknowledges s/he wants to participate and understands to an appropriate developmental degree what it entails;
- Parents have expressed understanding that they need to be equal partners in the process (support strategies, encourage child);
- Parents understand the program is free during the pilot phase and that any meetings with team Specialist will not be charged; however, any appointments with the child’s physician will be billed as usual and customary.
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. The questionnaire will continue to be used as a “diagnostic” tool to more closely examine the psycho-social-emotional and biological risk and protective factors impacting a child’s learning and health.
CSS Specialists and APD’s pediatric health care providers work together to deliver a more holistic approach to addressing the school-related challenges that may present during well-child and acute office visits. Learning specialists and behavior/health providers trained by CSS are on-site at APD four days a week (during after-school hours) to serve as resources and intervention Specialists working as a team with the primary care provider. The team also includes a program coordinator who serves as the point person to coordinate any actions that need to be taken/communicated (to the team, family, school).
Rx for School Success Pilot
As a pilot effort, designated APD primary care providers are gaining the knowledge and skills to use the assessment tools to facilitate school-age problems during well-child and other office visits. If the pre-screener results highlight trouble areas related to learning or behavioral/health issues, the provider is able to 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 family.
Once piloted with the APD pediatric population (June 2016-July 2017), CSS and APD will determine the most promising and effective components in order to scale the model and offer it to other interested Upper Valley primary care providers to use in their own practices. During the pilot there is no cost to families for taking the pre-screener or health and learning questionnaire. There is also no cost for meeting with the program coordinator or the Specialists.
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 occurred 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.
One of the benefits of working with an established health care organization is access to any number of metrics to measure outcomes. During Phase 2 of the project, CSS met with the data analysts at APD to determine the most useful statistics to collect during the pilot. These will include: reason for visit; patient demographics; number of times a child is seen for the same school-related concern; billing and reimbursement rate for services offered (by insurance company). Other useful measurements include an efficacy survey for participating providers regarding their level of comfort addressing school-related concerns prior to and after the training/pilot, and a satisfaction-level survey for parents regarding the care their child received during the program. In addition, we will be hiring a statistician to evaluate the correlation between screener and questionnaire, as well as their specificity and sensitivity with the intention of validating the two assessment tools.
Leslie Williamson, Executive Director, Center for School Success
Email: Lesliewilliamson11@gmail.com; Phone: (603) 298-6700