Challenges and Solutions in the Implementation of the School-Based Pathway to Care Model

School-Based Pathway to Care Model and Its Components

The School-Based Pathway to Care model (Figure 1) was first created in 2009 to address adolescent mental health through facilitating an holistic collaborative framework including educators and health care providers within the context of a secondary school setting (Wei et al., 2011). It addresses pathways into and through the most appropriate mental health care as well as the linkages amongst various components necessary for successful implementation of that pathway by identifying key stakeholders and describing key functional components, such as capacity building through training, and integration of health and human services providers both within and external to the school setting. Key stakeholders identified include the following: students, teachers, student services providers (e.g., guidance counsellors, school psychologists, school social workers, and school health centre staff), school administrators, parents/families, and health providers (primary care and specialty mental health services). Capacity building through training includes the following: mental health literacy for students and teachers (the Mental Health and High Schools Curriculum Guide (the Mental Health Curriculum) and teachers training program (Sun Life Financial Chair in Adolescent Mental Health & Canadian Mental Health Association, 2007), early identification of, internal and secondary triage and ongoing student support for youth with mental disorders (the “go-to” educator training program), and on-site or community-delivered evidence-based mental health interventions (primary care training programs).

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Figure 1.

School-Based Pathway to Care Model.

Formal and informal linkages into and through the pathway to care are created by application of the model components with key stakeholders participating in collaborative training experiences. For example, the “go to educator” training is primarily directed towards teachers and other school staff who students usually “go to” when they have a problem. It helps teachers better understand the mental health and common mental disorders in adolescents, assists in the identification of youth at high risk for having a mental disorder, provides information on useful support strategies (and identifies limits of teacher responsibilities), and reinforces within school mechanisms for triage and student support. However, joining these sessions are student support staff (e.g., guidance counsellors, school psychologists) and local health and human services providers (e.g., mental health and addictions program staff, primary care clinic staff). This common training reinforces common understanding and communication and enhances or may create cross-jurisdictional linkages that then can better facilitate the progress of an identified student into and through care (including return to school).

Experiences of the School-Based Pathways to Care Model

This model, although heuristically appealing, must stand the test of empirical validation through both quantitative and qualitative evaluations. Below, we describe various components of the development of this validation process, demonstrating a hierarchical approach to its evaluation and including preliminary research conducted by the developers of the model and research conducted by independent scholars.

Pilot of the Model in Whole With a Local Secondary School

Participants and Process

The model was applied and evaluated at a rural Nova Scotia high school under the direction of an implementation team including the school principal, school guidance counsellor, Student Services staff from the Department of Education, and the Schools Plus program coordinator by the knowledge translation team (the Team) that developed this model. All Grade 10 students (n = 74) and classroom teachers (n = 6) participated in the Mental Health Curriculum component. The “go-to” educator training included teachers, guidance counsellors, school psychologists, and local mental health/addictions and human services providers. Primary care involvement was linked through the local District Health Authority.

Model Component 1—Mental health literacy for classroom teachers and students

Mental health literacy refers to the appropriate understanding of mental health and mental disorders, knowledge and skills about stigma reduction, and enhancement of appropriate help-seeking behaviours. Mental health literacy (addressed through the Mental Health Curriculum and training programs) is foundational to the model. The Mental Health Curriculum (Sun Life Financial Chair in Adolescent Mental Health & Canadian Mental Health Association, 2007) was applied by six Grade 10 classroom teachers. It consists of a teacher self-study package and six modules for students. The self-study package provides basic information about mental health/mental disorders contextualized for the school setting. The six modules for students address the following: (a) stigma, (b) understanding mental health and mental illness, (c) specific mental disorders typically onsetting during adolescence, (d) lived experiences of mental illness, (e) help-seeking and support, and (f) the importance of positive mental health.

To facilitate the teaching of the Mental Health Curriculum, the Team designed an accompanying training program for teachers. The training was held in February 2010 for all participating teachers. This included an overview of mental health and mental disorders contextualized for the school setting as well as a review of the Mental Health Curriculum, with supplementary educational resources and teaching strategies. Following the classroom teacher training, teachers prepared class materials together and taught them in groups of two teachers with each group teaching two modules. The Mental Health Curriculum was delivered over a period of 1 week, taking approximately 8 hours total duration.

Model Component 2—“Go-to” educator training

“Go-to” educators are school staff (such as teachers, coaches, and guidance counsellors), known to principals, whom students frequently go to when they need help or advice. As such they are uniquely placed to identify students at high risk for having mental disorders if they are trained to do so. Based on a needs identification evaluation conducted by the Team, a “go-to” educator training program was created to address the understanding of mental health and mental disorders; identification of mental disorders, stigma, evidence informed support; professional and institutional responsibilities and their limits; triage principles and processes; and linkage to local mental health care providers (specialty services and primary care). The training was delivered in March 2010 to a group of “go-to” educators plus local mental health/addictions and community human services providers.

Model Component 3—Parents/family engagement

Strategies to involve parents and families were discussed throughout the process. The school suggested that a combination of online information and face-to-face information sessions as a way to improve the understanding of mental health by parents and families. The Team proposed providing information on the school website, by emailing fact sheets to parents, along with three information sessions at three sites within the school’s catchment area. The Team designed all the materials needed for the school to upload on to their website; however, the information sessions were not delivered due to logistical complications, especially the lack of transport for parents to attend the sessions.

Model Component 4—Primary care team mental health training

General practitioners and other primary care providers are often a youth’s first health contact, and therefore it is essential that they are able to properly identify, diagnose, and treat many of the common mild to moderate mental disorders in young people. Working together with the school, the District Health Authority invited general practitioners and other primary care providers to participate. The Team conducted a needs assessment with eight general practitioners and a paediatrician in January 2010, who identified training needs in five areas: Depression, Social Anxiety Disorder, Panic Disorder, Attention Deficit Disorder, and Obsessive Compulsive Disorder (OCD). On review, OCD was considered to be more suitable for direct referral to mental health services and a training program addressing the other domains was created. However, due to changes in the administrative structure of the District Health Authority, this program could not be delivered.

Model Component 5—Establishment of the pathway into care and referral mechanisms

“Go-to” educators and local mental health care providers were brought together at the “go-to” training to identify strategies to facilitate linkages between the school and providers. An in-school triage process for identified students was created and a single point of referral contact between the school and mental health team was determined. A method of tracking and assessing types of referrals and an ongoing support feedback loop was created. Issues pertaining to confidentiality were raised and clarified.

Program Evaluation

Both quantitative and qualitative techniques were used in the evaluation. Students and classroom teachers were administered the same questionnaire before (t0) and after (t1) the training, and at a 3-month follow-up (t2). “Go-to” educators were tested with another questionnaire matching the training content before (t0) and after (t1) the training, and at a 3-month follow-up (t2). The evaluation of referral process was documented on forms created for this purpose, tracking the number of students through the referral process and documenting what mental health care needs are were identified. Two focus groups (students and teachers, separately) were conducted to gather feedback on the interventions.

Student quantitative data were imported into statistical software (STATA) for analysis. Student mean scores were calculated and compared using t test. Mean scores of classroom teachers and go-to educators were also computed but not compared with t tests due to the limited number of participants (n = 6). Qualitative data were analyzed using a grounded theory approach to identify relevant themes. When completed, the program evaluation was posted in the public domain as noted above.

Results

Students’ mental health knowledge increased significantly (M = 59.3 [t0]; M = 72.2 [t1]; p < .001), immediately after the curriculum delivery, but this was not retained at the 3-month point (M = 57.8; Figure 2). Both teachers’ (M = 76, SD = 7.9 [t0]; M = 88, SD = 3.6 [t1]; M = 89, SD = 8.4 [t2]) and “go-to” educators’ (M = 77, SD = 10.8 [t0]; M = 87, SD = 6.7 [t1]; M = 81, SD = 12.9 [t2]) knowledge increased significantly and persisted over the 3-month period.

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Figure 2.

Change in students’ score on knowledge test over time (pilot of the whole model)

Student focus group discussions generated a number of themes. First, students reported feeling more comfortable responding to people with mental illnesses after taking the Mental Health Curriculum. Second, they suggested mental health training should be provided to parents and teachers since they often seek help from them. Third, they wanted more digital resources and interactive classroom activities in the Curriculum. Fourth, they reinforced the need for integration of the material into usual educational structures, such as examinations. Reports suggested that since they were not going to be examined on the material prior to the final post-test, they did not approach the Mental Health Curriculum with the same diligence as subjects in which examinations were applied.

Classroom teachers identified three areas for improvement: enhancement of education about the brain, more integration of local community resources in classroom presentations, and the clarification of policies regarding parental consent and confidentiality. “Go-to” educators requested more in-depth training pertaining to mental health services system navigation and additional mental health resource toolkits. Both classroom teachers and “go-to” educators reported that the model helped integrate the school with the local mental health care provider to better meet students’ mental health care needs.

The process evaluation indicated that, compared with the previous year, the number of referrals did not significantly increase over the project period (December 2009-June 2010), as some health providers expected. However, the quality of the referrals increased (referrals were judged to be “more appropriate for mental health services”), and both school and mental health clinic staff reported improved working relationships. Concerns about consent and the lack of a common consent form across education/health systems were raised and brought to senior administrative levels in the Provincial Departments of Health and Education for clarification and address. This led to clarification of misperceptions related to consent held by educators and the creation of a process to develop a common consent form to be used across Departments.

Discussion and Lessons Learned

Experiences in the application and ongoing development of the School-Based Pathway to Care Model indicate that it is possible to implement the model as a whole or to apply individual components that serve the goals of each component within the wider framework of enhancing system capacity for addressing mental health care needs of secondary school students. This dialectic or praxis process has provided rich program evaluation data that have been used to improve the components of the model and to inform approaches to its application. Following are key lessons learned.

First, it is necessary to identify local champions within education and health sectors (primary care and mental health) that can help apply the model and mould it to fit local realities. These champions also serve to help overcome obstacles within and across systems. These champions ideally could be brought together as an action committee to develop, apply, and evaluate the model as well as engaging key players from the different sectors involved. The “go-to” educator training sessions provide an ideal opportunity for these champions to engage their representative communities and to begin to establish or enhance linkages between schools and health providers: both formal and informal. These linkages require both personal and system-level participation to help establish and reinforce their application. The combination of formal (system administrative structures) with informal (combined training) approaches to integration seem to be a key component for success.

Second, there is no “best” application of the model. Its flexibility allows locations to choose the components that they wish to or have the ability to apply. Additional components can be applied as local opportunities permit. For example, although primary care capacity in diagnosis and treatment of adolescent mental disorders is part of the model, two of the jurisdictions were not at the point to develop this component of their health care delivery system. In another setting, this was able to proceed because a commitment had been made to address this issue. This feature differentiates the model from programs that demand a high degree of fidelity for application. The flexible nature of the model and its ability to show good outcomes without demanding fidelity are particular strengths, as this allows the model to meet the needs of people and settings rather than the other way around.

Third, supplementary mental health resources available at a single point of contact are useful to teachers applying for the Mental Health Curriculum. As a result of these lessons, the Team has established a wealth of such resources, both on its own website (www.teenmentalhealth.org) and in collaboration with Taking It Global (www.tig.com), an international educational resource. Embedded in the (teenmentalhealth.org) website is the ongoing development of a repository hosting mental health resources screened and validated to meet criteria for quality and classroom utility for teachers. An online discussion forum for teachers is also soon being added to this online resources repository.

Fourth, train-the-trainer and online learning approaches will be necessary for the broader dissemination of the model and its various components. The Team is now responding to this need by building e-learning modules on their website (www.teenmentalhealth.org) and creating train-the-trainer programs.

Fifth, at the systems level, it is important that both Components 1 and 2 of the model be addressed concurrently. Putting the Mental Health Curriculum into place without implementing the in-school capacity to recognize and respond to students with mental disorders is unfair to students, schools, and providers alike. School boards are thus encouraged to simultaneously address both components. As an example of this understanding, the new educational strategy for the Province of Nova Scotia, Kids and Learning First (Nova Scotia Department of Education, 2012), has incorporated this lesson into its approach in addressing school mental health in the Province.

Meanwhile, we note that there are some challenges that need to be further addressed so that there can be improvement in the model’s application. For instance, it remains challenging to link primary care with the school system, although this component has shown early promise in British Columbia. To change current primary care practice and to better integrate mental health care into primary care will require substantial support from policy makers and related stakeholders. Perhaps the approach currently being applied in parts of British Columbia will inform responsible parties as to the value of and need for this approach once the program evaluation has been completed and can be disseminated. Another major issue is that of measurement of mental health literacy for each group of the participants—students, teachers, student services providers, health providers, and so on—needs to be refined. The development of this part of the school mental health field is in its infancy and members of the Team have identified this as an upcoming priority. Lastly, although work to date has demonstrated encouraging results, more rigorous research has yet to be conducted to provide stronger evidence for both short- and long-term outcomes of the model application.

Nonetheless, and with the above caveats considered, we feel that there is reasonable comfort in the data currently available to support the implementation of the School-Based Pathway to Care Model, especially its tested components, such as the Mental Health Curriculum, its companion teachers training program, and the “Go-to Educator” training program. To our knowledge, the Mental Health Curriculum is the only evidence-based high-school mental health curriculum available globally, and the approach that is applied within the School-Based Pathway to Care Model is consistent with national mental health policy considerations such as they have been articulated in both Evergreen (Kutcher & McLuckie, 2010) and the Mental Health Strategy for Canada: Changing Directions, Changing Lives (http://strategy.mentalhealthcommission.ca/). Further independent research directed towards various components of the model, especially with regard to linkage to and interaction within primary care, would be very useful.