Schools and Health: Our Nation's Investment (1997)

Maine Goals 2000 Study Group

Jacqueline Ellis, Facilitator

Spring 1995

Our vision includes the following elements:

• Communities provide all families and children from birth through school completion with the educational, social, and health services needed to enable children to grow and learn to their full potential. Children are ready to learn when they enter preschool or school, as well as being ready to learn every day throughout their school years and beyond.

• The integration of services involves attitudinal changes about and structural changes in the ways that the needs of children and families are met.

• Service providers work as partners with each other and with families and schools.

• The focus of these services is on prevention.

• Services are integrated to maximize access to and make efficient use of resources.

The Study Group on Integrated Services developed the following recommendations during the spring of 1995. We applaud the Task Force's recognition of the significance of integrated services in helping to give

children an equal opportunity to learn, and we appreciate the opportunity to share our knowledge and experience about this topic.

1. The human services needs of children and their families are urgent and growing. Many children do not receive the services they need in order to learn and to reach their full potential. The National Commission on the Role of the School and the Community in Improving Adolescent Health issued a ''Code Blue" alert:

   For the first time in the history of this country young people are less healthy and less prepared to take their places in society than were their parents and this is happening at a time when our society is more complex, more challenging, and more competitive than ever before (National Commission, 1989).

2. The current system is not working. Services are often fragmented, duplicative, or underused. They are more frequently driven by funding sources and program guidelines than by the needs of children and families.

3. Meeting the needs of the whole child would enhance the ability of children and teachers to focus on learning.

4. Integrated services make more efficient use of limited funds.

5. Coalitions are more capable of addressing multifaceted problems effectively and can accomplish more toward reaching common goals than organizations can when working independently.

The following statistics exemplify problems in Maine that interfere with learning and that can be addressed more effectively by integrated services:

• Thirty-seven thousand (12 percent) juveniles live in households with incomes far enough below the federal poverty line that they qualify for Aid to Families with Dependent Children (AFDC). The proportion of youth living in poverty has been steadily increasing.

• Nearly 30 percent of teenagers say they have seriously considered killing themselves, and 10 percent have tried to commit suicide at least once.

• Ten percent of all births are to unmarried teens who have not completed 12 years of school.

• More than one-fifth (21 percent) of youth report having carried a weapon such as a gun, knife, or club during the past month. This figure is for in-school youth in the safest state in the nation!

• One-half of teenagers use alcohol, with 25 percent of the girls and 32 percent of the boys drinking five or more drinks in a row.

• Support services, instruction, and administration or management are equally important components of successful school improvement and the development of healthy children.

• Support services are only one aspect of the increased family and community involvement in education necessary to improve children's learning. Indeed, it takes a village to raise a child.

• Effective prevention programs set high expectations for children and families, focusing on their strengths and the gains that they can make when given adequate support and appropriate services.

• School staff, such as guidance counselors, health educators, and school nurses, are potential facilitators of integrated services and provide critical links between other school staff, students, and community service providers.

Numerous organizations—such as the National Association of State Boards of Education, the National Education Association, the National School Boards Association, the National Association of Towns and Townships, the American Association of School Administrators, and the Carnegie Council on Adolescent Development—stress the interrelatedness of child health and learning and the pivotal role of schools in helping address these issues. Strong national support is reflected in Maine by position statements from such organizations as the Maine School Boards Association, the Maine Coalition on Excellence in Education, and the Maine Principals Association.

A 1992 national Gallup poll indicates strong public support for the school's involvement in service delivery. More than three-fourths (77 percent) of respondents favored using public school buildings to provide health and social services to students.

Study group recommendations are based on the following:

• a panel discussion of innovative Maine efforts to integrate services;

• a brief review of effective national programs;

• the results of a small survey of stakeholders in Maine;

• feedback from local focus groups on integrated services convened by the Maine Leadership Consortium in 1993;

• the comments on draft recommendations distributed to more than 40 reviewers (see list of reviewers at end of this appendix);

• the professional experiences of study group members who represent diverse perspectives and stakeholder groups (see list of members at end of this appendix).

Our recommendations were limited in depth and scope by the time available. The study group could offer more information later that would be more appropriate and useful for local schools and communities as they attempt to integrate services.

The following recommendations are organized by the issue areas or strands that emerged during our research. They attempt to address the barriers as well as to incorporate the effective strategies discussed. The strands in Part I describe what type of services are recommended and how services would be designed and delivered at the local level. Part II describes state and federal support for local efforts. All these strands need to be woven together to provide a seamless web of services for children and families.

The recommendations in this section are directed toward local communities. Local communities would decide on the exact type of services to meet the needs of their children and families (see Section A) and would select a convener for this effort (see Sections C and D).

1. Provide integrated services that are

   1. comprehensive: a full range of basic social and health services to support educational services (see list of integrated services in Part II);

   2. child-centered: services that focus on children, from birth through school completion;

   3. family focused: services that address the needs of children within the context of the family;

   4. flexible and equitable: services that meet the changing physical, emotional, social, and educational needs of children and families;

5. preventive: emphasize primary prevention as well as providing intervention and treatment.

Note: Other definitions related to the recommendations appear at the end of this appendix.

1. Establish contact between service providers and families of children before or at birth. A positive relationship would be initiated by hospitals through existing prenatal, sibling, and/or family classes or by providing visits from community health nurses. Maintain continuity of care from birth to school completion through collaboration by service providers, childcare providers, and preschool and public school staffs. Examples are: Healthy Families, Even Start, High Scope, Parents as Teachers, Headstart, Success by Six, Child Development Services, Division of Public Health Nursing, and Bureau of Children with Special Needs.

2. Provide low-barrier services for all children. Practices that increase accessibility include providing childcare and transportation , locating services in a central location(s) ("one-stop shopping"), reducing or eliminating eligibility requirements, and providing affordable care.

   Schools represent an excellent potential location or conduit for services because of their regular contact with children. Research indicates that most successful collaborative services are located in or near school buildings. Administration of services seems to work best when done by service providers who are accountable to their agencies and who work as partners with school administrators or their designees. Consider using school space after class hours, utilizing space or facilities near a school, and planning space for service delivery in the design of any new school or community center.

3. Develop a single, straightforward form or method of gathering information from families and children; this is known as "universal intake." Agree upon a common entry point for those receiving services (e.g., a school, health clinic, or town office). Other institutions, such as employers or hospitals, would refer families with children to this entry point.

Note: The following recommendations are essential for addressing the significant attitudinal barriers to fundamental changes in service delivery.

1. Develop a shared vision for integrated services among diverse families, students, providers, school staff and boards, community leaders, and other community members. This is an important early step of program development.

2. Build and maintain trust and commitment among schools, families, service providers, students, and other community members during the preplanning and planning phases. This takes a lot of time and patience but is essential to making lasting changes in service delivery.

   One way to build trust and commitment is to hold neighborhood meetings, study circles, or community forums. These sessions could be used to provide input to the steering committee (see Section D).

3. Create a safe physical and emotional setting for those giving and receiving services. This can be achieved by respecting individual differences (including educational and economic level, gender, and disability), developing interagency partnership agreements, establishing clear policies and procedures regarding confidentiality, and providing opportunities for ongoing public dialogue about services.

4. Address potential concerns about loss of control and authority, uncertainty about new roles, differences in approach, and other sources of conflict early in the process. Set up a mechanism with written procedures to address these directly and regularly.

5. Provide opportunities for ongoing, two-way communication with the general public about available services, the purpose of integrating services, and the vision for integrating services in their community. Examples are: newsletters, open houses, the Internet, media coverage, and surveys.

6. Set high expectations for the health of children and the quality of services that are similar to those set for student achievement.

1. Select a neutral and respected leader to convene a community-wide effort to integrate services. Examples are a: town manager or planner, school superintendent, businessperson, United Way, family or children's advocate, librarian, or service provider.

2. Create a steering committee with appropriate staff resources that is representatives of all stakeholder groups. Involve these groups in decisionmaking during all parts of the effort to improve services (i.e., from assessment, to development, implementation, and evaluation). These stakeholder groups should include but not be limited to parents and other primary caregivers, youth, senior citizens, service providers, churches, school administrators, and other community leaders.

3. Give specific individuals within service delivery and other stakeholder groups responsibility for assisting with integrated services, including participation on the steering committee. These responsibilities become part of their job description and evaluation.

4. Inventory and reassess existing structures and processes for service delivery. Build on effective processes such as that used by school Student Assistance Teams (SATs).

5. Identify and provide resources to support case coordinators for multidisciplinary teams. These teams would share information and plan strategies with families and children to address areas of concern.

1. Restructure the preservice training of health, education, special education, and social service professionals to better meet the needs of the whole child. Without adding more courses, arrange for preservice education to include training on the roles and responsibilities of different professionals and on effective strategies for collaborating to deliver integrated services. Examples are: shared course work, skills training, field placement, job mentoring, and panel discussions. Adjust certification requirements to reflect these changes.

2. Provide ongoing professional development for those delivering and making decisions about services. Providers need training on such topics as communication, collaboration, team building, the roles and responsibilities of professionals from different disciplines, conflict resolution, grant writing, and confidentiality. Use a training-of-trainers model,

with experts providing professional development and technical assistance to enable local leadership teams to do their own training and work.

1. Build in time on the job for individuals responsible for integrating services to complete relevant organizational activities. Examples are: case coordination, training, and evaluation.

1. Change the ways in which existing public funds and other resources are used; much can be done with existing funds.

   Shift the balance of funding more toward primary prevention services, especially for young children. United Way estimates that every dollar spent in early childhood development saves society 6 dollars in remedial education, welfare payments, and court and prison expenses.

2. Search for additional funding from businesses or respond to requests for grant proposals (RFPs) only after developing community ownership and trust and after examining existing public resources and practices.

3. Take advantage of all available resources, including the skills, time, and energy of volunteers. People are our greatest resource.

4. Maximize the use of public and private insurance options for funding services. An example would be: Medicaid.

5. Use any savings resulting from the integration of services to increase services, provide services at less cost, or enhance the system's ability to collaborate.

1. Set clear and manageable goals for service delivery based on the vision developed by a steering committee. Evaluate and document progress toward goals. Involve key players in periodic reflection on and documentation of successes and failures, as well as on the factors affecting progress. Use this process to guide and adjust objectives, activities, and use of resources.

2. Use multiple qualitative and quantative strategies to evaluate the impact of integrated services. Qualitative evaluation strategies could include:

case studies, interviews, observations in class and in the home, and feedback from family members. Establish a centralized database and track youth-related statistics to provide information for quantitative evaluation components.

3. Recognize and celebrate the efforts of those who collaborate to deliver more relevant and efficient services to children and families.

1. Increase cooperation and collaboration among the commissioners and the Departments of Education, Human Services, Corrections, and Mental Health and Retardation, and the Office of Substance Abuse. Governor King's attempt to rejuvenate the Interdepartmental Council ("Children's Cabinet") could lead to the types of changes in state government that are critical to fundamental and sustainable change at the local level. Related recommendations follow:

   1. Make the structural changes that may be needed to facilitate interdepartmental collaboration.

   2. Develop public policies and legislation that enhance the flexibility of local providers and state agencies in meeting children's needs. Eliminate policies and regulations that act as barriers to the integration of services.

   3. Standardize the regions that state government and relevant statewide nongovernmental organizations use to organize funding, personnel, and services.

   4. Combine categorical sources of funding from the state and federal government into one pool, the use of which is decided upon by local communities.

2. Plan a Blaine House Conference on integrated services for key stakeholder groups at the state and local levels. This would be an excellent catalyst for local communities to reexamine and begin to plan improvements in service delivery. It would also provide an opportunity to recognize and learn from communities that are currently collaborating. Organize a follow-up session to check on progress toward integration of services.

The Maine Education Goals 2000 Study Group envisions a full range

of basic social and health services being integrated with educational services to help ensure that children and adolescents have an equal opportunity to learn. These services include but are not limited to the following list. Note that many could be listed in more than one category.

Candace Crane, Director of School Services (Millinocket)

Ruth Davison, Reading Coordinator, Chapter One Director (Boothbay)

Debora Duncan, Guidance Counselor (Randolph)

Jacqueline Ellis, Educational Consultant, Study Group Facilitator

Barbara Estes, Bureau of Children with Special Needs (Bath region)

Denison Gallaudet, Task Force on Learning Results, businessperson

DeEtte Hall, Division of Maternal and Child Health (U.S. Department of Health and Human Services [DHHS])

Thomas Hood, Principal, Montello School (Auburn), Task Force on Learning Results

Debra Houston, Director of Special Services, SAD #53, (Pittsfield)

Orene Nesin, Maine School Boards Association, Task Force on Learning Results

Arlene Nicholson, Guidance Counselor, School Board member, Task Force on Learning Results

William Primmerman, Maine Department of Education (Augusta)

Wendy Pullen, Director of School Health Center (Dover-Foxcroft)

Christine Snook, Special Needs Parent Information Network (Hallowell)

Cheri Stacy, Partnerships for a Healthy Community (Bangor area)

Meredith Tipton, Director of Public Health Division (City of Portland)

Patti Wooley, Director of Headstart (Waterville)

Gail Werrbach, School of Social Work (University of Maine at Orono)

Myrt Collins, Principal, Jack Elementary School (Portland)

Donna Finley, Family Development Specialist, Western Maine Community Action Program (Auburn)

Roger Merchant, Piscataquis County Cooperative Extension (Dover-Foxcroft)

Kenneth Schmidt, Director, Regional Medical Center at Lubec (Lubec)

Michael Brennan, Maine House of Representatives (Portland)

Paul Brunelle, Executive Director, Maine School Management Association

Michael Clifford, Substance Abuse Counselor, Portland Schools

Myrt Collins, Principal, Jack Elementary School (Portland)

National Commission on the Role of the School and the Community in Improving Adolescent Health. 1989. Code Blue: Uniting for Healthier Youth. Alexandria, Va.: National Association of State Boards of Education.