Case Study: A Clinic and a School District Team Up to Help Kids

Lack of Communication as a Barrier to Care

For the past 40 years, Santa Cruz Community Health Centers (SCCHC)  has provided quality, affordable, comprehensive health care services — from primary care to acupuncture treatment — to 10,500 people in the city of Santa Cruz and the surrounding area. Many families who live in Live Oak, an unincorporated community near Santa Cruz, rely on SCCHC for medical care.

Live Oak has a large number of low-income residents: 57 percent of the students in the Live Oak School District are low-income, 54 percent are Latino, and as many as 25 percent of the students at one elementary school are homeless. Many students struggle academically: At Live Oak Elementary School, for example, only half of third grade students read at grade level.

SCCHC and Live Oak School District staff were frustrated that many of their high- risk, high-need students, who have complex health, family, and academic needs, weren’t showing much improvement. These young people often have multiple barriers to care, including poverty, social isolation, disorganized home environments, parental trauma and mental health issues, and illiteracy. These factors lead to decreased school attendance, missed clinic visits, and lack of follow through on care plans and academic remediation, all of which further prevent the children from getting the care they need.

SCCHC and school staff recognized yet another barrier to care: there was little communication between healthcare providers, teachers, and parents. As one SCCHC staff member put it, “Health providers were in the dark about how their patients were faring at school, educators were at wit’s end with their students’ complex health and family needs, and parents were disengaged, overwhelmed, or confused about how to support their high-need children.”  

School and clinic staff alike recognized that this situation wasn’t serving the young people who were at highest risk, and they decided to do something about it.

School-Clinic Collaboration

To get started, staff at SCCHC and the Live Oak School District launched the Live Oak Community Care Team. To build and guide the Team, staff tapped into an existing resource: the Live Oak Cradle to Career Initiative (C2C). C2C was created by parents at the Live Oak Preschool and local health, education, and social service representatives to create an integrated support system for high need families.  Since its founding four years earlier, C2C has helped build relationships between participating institutions, and these bonds helped build a strong foundation for the Community Care Team.

C2C’s Social Impact Consultant was brought on as the Community Care Team’s facilitator, and a Leadership Group was formed. The Leadership Group worked together to create a structure for the new group, and to decide goals and processes. They shared their plans with SCCHC and school district staff, who provided feedback and recommendations.

SCCHC obtained a grant from CCI, and subgranted monies to the Live Oak School District to solidify the partnership. The CCI grant was used to cover a percentage of clinical staff time, consultant hours, the subgrant to the school district (to supplement counseling and clinic staff time); a small portion was used for food and miscellaneous expenses. CCI also provided project support, coaching, and access to data, fundraising, and legal expertise.

The Leadership Group designed a plan for Community Care Team Case Conferences. The Case Conferences are meetings where an interdisciplinary group of health care providers, educators, and social service representatives gather to consider the cases of high-risk students, and formulate care plans. The Leadership Group created an agenda for the conferences, figured out the process for Release of Information (ROI), and created a conference evaluation form and a case tracking form (the latter proved hard to use and was later replaced with a simple spreadsheet.)

Case Conferences focus on one to two students (when two students’ cases are considered, the conferences are divided into two time slots, with the group discussing each student individually). First, the Community Care Team listens to a three-minute audio recording of the child’s parent. In the recordings, parents discusses their hopes and dreams for their child. Next, clinic and school representatives give their respective observations of the student, including family situation, health concerns, treatment and referrals, Individual Education Plans, school attendance, behavior, and other information. The group then works together to identify system-level solutions and to develop unified care plans. Staff are assigned follow-up tasks. (See Community Care Team Case Conference Agenda for more detail.)

The Community Care Team met monthly, holding a Case Conference and a Leadership Group Meeting in alternating months. The Leadership Group meetings provided the opportunity to plan conferences, follow-up on ongoing cases, refine the agenda, address data management issues, and regularly review and improve project goals and practices.

Results

Participants in the Community Care Team Case Conferences were universally positive about the experience. Health care providers and educators alike expressed the value of sharing information and different perspectives on the children in their care (see companion video).

“Sitting in the Case Conference, you learn so much about a child from a 360 degree perspective,”  observed SCCHC CEO Leslie Conner. “Primary care providers only get a snapshot. They see a child for 30 minutes, perhaps, whereas a teacher sees that child for six or seven hours, five days a week. By bringing the two institutions together, you get a whole picture.”

Del Mar Elementary School principal Marilyn Rockey is pleased that the school-clinic collaboration will help high-risk students finally get the support they need. “We suddenly have access to these incredible services that will touch the whole child — far beyond what we could do as a lone school site,” she pointed out.  “Being able to go in tandem and become a partnership was really an incredible gift.”

For Patty Tausheck, a teacher at Del Mar Elementary School, the experience provided a sense of the value of the work she does every day: “It’s been so impactful to just be asked my opinion after all these years, to have someone who wants to include me in something like this.”

Parents were also pleased to have more intensive and coordinated support. Many felt at a loss for how to help their struggling student. In some cases they felt they were receiving contradictory messages from the various “experts” in their child’s life, and weren’t sure where to turn. The fact that their child now had access to coordinated care from both school and clinic staff was an immense relief.

As one clinic staffer put it, “On multiple occasions during the project, both parents, teachers and providers have been moved to tears with relief in being able to come together to share information and find solutions that cannot be found in a classroom or exam room alone.”

 

A closer look at what worked:

• Bringing partners together for face-to-face conferences strengthened relationships and fostered a deeper level of communication and coordination. Practical steps like sharing cell phone numbers created opportunities for real-time coordination and follow-up.
• Starting each conference with an audio recordings of parents’ concerns, hopes, and dreams for their children was a way to bring parents’ voices to the table and ensure the conferences were responsive to their needs without including them in a potentially intimidating meeting with 15 to 20 “experts.” This also gave agency partners the opportunity to be vulnerable and share questions and challenges more openly.
• Having a dedicated facilitator/consultant helped with project management and ensured effective use of time during Leadership Group meetings and Case Conferences.

And what didn’t work:

• Strict privacy regulations known as HIPPA (Health Insurance Portability  and Accountability Act) and FERPA (Family Educational Rights and Privacy Act)  create significant barriers for the school and clinic to create a data sharing platform. The original case tracking form created by the Leadership Team proved to be burdensome and redundant, so clinic and school  staff entered notes into their respective electronic case records, and created simple spreadsheets to track each case. Because of HIPPA/FERPA, these spreadsheets could not be shared electronically with the full team, and instead “lived” with the respective clinic/school point person, except when they were printed out and shared in Leadership Group meetings.
• There were several key staff transitions mid-project, which was disruptive to the continuity of planning, tracking cases, and coordination.
• While many parents were glad to have the additional support and comprehensive care plans, other parents were not responsive. The students at highest risk for academic failure required the most amount of follow-up and had the least parental engagement. Apart from Child Protective Service representatives, there is no one who can go to the home to assess needs of a parent who is unwilling to accept care.  Most organizations that can make home visits (Parents Center, Public Health Nursing) require parental permission to accept services before the organization can go to the home.

Measuring Success

The Live Oak Community Care Team’s first Case Conference was held in February, 2018; its sixth in December, 2018. While the cohort of students is small, initial results are promising.

A total of 8 students’ cases were reviewed:

• 8 Live Oak elementary school students (with a combined total of 13 siblings <18 years)
• 7 males, 1 female
• 8 low income
• Average age 8 ½ years old (from 5 – 13)
• 50 percent secure housing, 50 percent insecure housing
• 4 Latino, 3 white, 1 other
• 5 Non-English or bilingual
• Parents, grandparents, foster parents

Results:

• 5 families followed through on at least one care plan recommendation (2 didn’t, 1 is pending) following the conference
• 3 students had increased school attendance following the conference (2 no change, 3 info not available)
• 2 students had positive classroom behavior changes following the conference
• 2 students had increased academic engagement following the conference
• 6 students had progress in at least one personal goal area

40 school and clinic partners participated, including:

• Teachers
• Principals
• Resource Specialists
• School Psychologists
• School Counselors
• School Director of Student Services & Special Education
• Clinic Pediatricians
• Clinic Behavioral health providers
• Clinic Pediatric Complex Care Manager
• Clinic Integrated Behavioral Health Care Coordinator Lead
• Clinic Executive Director

School and clinic partners submitted evaluations and 100 percent said they gained one or more benefits from each case conference, including:

• Better understanding of how to work with clinic/school partners (74%)
• Better understanding of how to guide students/patients with similar experiences (59%)
• Support and encouragement (59%)
• Increased knowledge of clinical tools and interventions (57%)
• Increased knowledge of school-based tools and interventions (48%)
• New ideas for how to work with students/patients like this (28%)

(Based on 61 evaluations submitted at 6 conferences)