ESTELLE SLOOTMAKER | THURSDAY, NOVEMBER 07, 2019
SECOND WAVE — MICHIGAN

This article is part of State of Health, a series examining integrated care and its potential to improve Michiganders’ health. It is made possible with funding from the Michigan Health Endowment Fund.

A new trend in pediatric care – offering behavioral health care at the pediatrician’s office – could not only cut costs but also create healthier, happier communities in the future.

“We know children eventually grow up and become adults,” says Michelle Duprey, director of integrated healthcare at Inkster-based Starfish Family Services. “Children with undetected medical and behavioral needs become adults who have more extensive and expensive medical and behavioral needs.”

The costs communities incur as a result aren’t limited to providing care. Adults with untreated mental health issues may find it difficult to hold onto family or relationships, and even harder to hold down a job. Communities not only lose productive members but also experience escalating costs associated with covering social services, substance abuse treatment, and, in some cases, court and incarceration costs.

“When it comes to programming for behavioral health and mental health, a lot of times our system makes rules and programs for adults and forgets the kids. Well, when we do the same thing for the kids (as for adults), it doesn’t work,” Duprey says. “Children have many developmental stages between (age) 1 and 21 and so many different risk factors. … (Mental health issues) you see in an adult started in childhood most of the time.”

Duprey is a national subject matter expert who literally wrote the book on PIHC: the Pediatric Integrated Health Care Manual. The focus of her career has been integrating mental and behavioral health into primary care, pediatric, and obstetric practices. It hasn’t been an easy task. For one, neither public nor private health insurance systems have developed fair payment systems for integrated care. Starfish Services’ projects have had to seek grant funding in order to keep integrated practices afloat.

Second, medical doctors often feel their role is solely to do medical work. They may fear that lack of time, training, and resources for referrals will make adding mental health services cumbersome and impractical. Duprey says she had to “pound the pavement” to find two pediatric practices to join the new program. One of the pediatricians was skeptical, but relented and let her give it a try.

“After a year, he said, ‘I don’t think I can practice without you. You’ve transformed my viewpoint of whole-person care and whole-family care,’” Duprey says.

Pediatricians who do give it a try find that integrating behavioral health into their practices creates efficiencies. When a patient makes a behavioral health need known, the pediatrician can hand the patient off and move on to their next appointment.

“The behavioral health worker provides resources, action plans, and brief interventions,” Duprey says. “If a client is identified as needing more help, we help them navigate that (mental health) system because we know it.”

Vice versa: Judson Center

With services in Wayne, Washtenaw, Oakland, Genesee, and Macomb counties, Judson  Center is integrating care the other way around. Historically a provider of behavioral health services, its latest project, launched in February 2019, adds primary care to its menu of services. Using the Patient Centered Medical Home Model (PCMH), the new clinic addresses patients’ needs holistically with consideration for their social determinants of health. In addition to medical and mental health, patients benefit from adjuncts like nutritional counseling, educational programming, and introduction to other community resources.

“We knew it was important to have a clinic that could provide whole-person care, most specifically to a behavioral health population,” says Susan Salhaney, chief operating officer of Judson Center. “We have our largest behavioral health clinic in Macomb County. 50% of those folks refer through community mental health. Two-thirds of them are children. Based on our surveying, many were not routinely getting the primary care they needed. Sometimes we think of children as little adults, but children’s behavioral health needs are distinct and impacted by stages of development.

Judson Center is partnering with healthcare management organization MedNetOne Health Solutions for the primary care piece of its practice. The partnership is a truly integrated model that allows for both practitioners to engage with a patient during the same visit. Patients with challenges like finding childcare or transportation are more likely to receive all the care they need when they don’t have to schedule additional appointments at another, potentially unfamiliar practice. Community health workers on Judson’s staff remove barriers to health by helping patients find transportation, food, or needed items – in one case, a vacuum cleaner.

In addition, this integration allows the staff at Judson Center to address issues like anxiety and depression that often accompany medical conditions, or to discover a child’s ADHD has been misdiagnosed and is really the result of having experienced trauma.

“When behavioral care with a child or family is addressed in a team environment, you can identify the condition with the behavioral health and primary care providers and see them both at the same time. It’s not, ‘We’ve identified this and now they have to make an appointment and travel five miles to see someone else,’” says Ewa Matuszewski, CEO of MedNetOne. “We’re looking at making primary care available at the point of care and establishing great relationships with the family or caregiver.”

Lunchtime chat yields transformational partnership

Alexandros Maragakis, assistant professor in Eastern Michigan University’s (EMU)  psychology department; and Blake Lancaster, assistant professor at University of Michigan (U-M) Medicine, met one day for lunch. Both were working on integrating mental health care into medical care practices – a pediatric setting, in Lancaster’s case. Both saw integrated health settings as the future of behavioral health care, and both agreed that traditional training didn’t properly prepare psychologists for that future.

So they decided to begin addressing that by creating the Michigan Medicine/EMU  Integrated Pediatric Behavioral Health Training Collaborative. The collaboration will provide specialty training in integrated behavioral health for doctoral trainees in psychology during their practicum, internship, and post-doctoral studies.

“(We decided that) if we started people at the practicum level and (continued) throughout their progress through the training pipeline, not only would they be more skilled but they’d … be able to go out into the field and start their own integrated health clinics,” Maragakis says.

The collaborative received a $326,000 Michigan Health Endowment Fund grant to get the program started. Maragakis says EMU will cover the practicum side of the programming, while U-M will handle intern and post-doctoral programming. He says the collaboration has led him to spend a lot of time at U-M, “creating new clinics and testing new methods of service delivery that otherwise would have been impossible for us to do.”

“We are creating a nice bridge between the university training side of things and the hospital training side of things,” he says.

Maragakis says the goal is to not only train practitioners for Michigan Medicine systems but to also equip a new wave of behavioral health professionals who will serve other medical systems throughout the state or open their own integrated practices — and reach the many underserved Michigan children who need behavioral health care.

“We know that the sooner we address behavioral health in children, the less likely it will impact them later on in life,” Maragakis says. “There is a lot of benefit to addressing problems as soon as possible for the child and family. The faster we can do that, the higher the chances (are that their) family follows through and the child gets access to care they need — and the more likely we can create an overall healthy community in the future.”

PUBLISHED JUNE 26, 2019 BY ERIN EINHORN – CHALKBEAT

It was a Friday morning in early May, just before Mother’s Day, when a group of preschool teachers settled onto oversized pillows and colorful beanbags for a conversation that would lead to tears, frustration and — eventually —  a sense of clarity on a delicate matter involving a child. 

Karen Massingille, a preschool behavioral health therapist, sat on a tiny child’s chair, looking at the nine women seated around her in a cozy, carpeted corner of the sunlit room.

She took a few deliberate breaths, then started to speak.

“It’s Mother’s Day,” she said. “Anybody have any plans?”

Her question seemed like a lighthearted inquiry and, indeed, it led at first to answers about planned barbecues and family gatherings. But Massingille’s goal was not lighthearted conversation. She wanted these teachers to talk about mothers — the ones in their own lives, and the ones in the lives of their students. She wanted to know their frustrations and their fears. And she wanted them to discuss them here, in this room, so they wouldn’t come out later in the classroom. 

The women around the circle work with young children at the Starfish Family Services Center on Hiveley Street in the inner-ring Detroit suburb of Inkster, where a third of residents live in poverty. The federally funded Head Start preschool program where they teach serves some of the city’s neediest families, including children who face hunger, violence, or fear at home.

These teachers see the impact of those challenges on their students every day — in the loud, disruptive behaviors they see in some children, or the quiet sadness they see in others. They fret about some of their students, bringing that worry home at the end of the day. For some, that can trigger difficult memories from their own childhoods. For others, it can affect their interactions with their own families. 

“It’s not every child you take home with you,” said teacher Melanie Swingle, who has worked at the Hiveley Street center for a year. “But some of our children, you think about them … You’re washing your hair and you’re like ‘I wonder if she’s going to get a shower today.’”

The weight of that worry is why the Hiveley center began holding regular monthly meetings like the one Massingille led before Mother’s Day. 

The sessions use an approach called reflective supervision that has long been used in the mental health field to help therapists and clinicians work with their supervisors to process their feelings about the difficult situations they see in their work. 

Reflective supervision is not used as often in education as it is in mental health. But Starfish Family Services, which runs the Hiveley center and 10 other Head Start centers in and around Detroit, started requiring all of its teachers to participate in group sessions like these four years ago as a way to help them cope with the stress of the job. 

The approach is part of a growing effort across the country to recognize and address the impact on educators of what’s known as “secondary trauma,” the distress that comes from learning about difficult things that have happened to others. 

As educational research increasingly highlights the role that trauma plays in causing challenging student behaviors and in influencing teachers’ responses to them, more schools are adopting what’s known as trauma-informed practices to help teachers better respond to their students’ needs. 

Kathleeen Mulrooney, a program director for infant and early childhood mental health for Zero to Three, an organization that promotes early childhood wellbeing across the country, said that work is especially important for teachers who work in early childhood education. 

“Babies and young children stir up very strong feelings in the adults that are a part of their caregiving network,” Mulrooney said. “And because brain development is happening so quickly [at that age]  … being able to shape that social emotional development in positive ways is of critical importance.”

Although early childhood educators don’t necessarily have higher rates of depression or anxiety than the general population, research has shown that an early childhood workforce that’s mentally healthy can provide higher-quality care to children, and that programs that build teamwork, respect, and stability at work can improve teachers’ mental health. 

That’s the motivation behind a number of steps that Starfish has taken to support teachers, said Brianne Twombly, who is the organization’s manager of trauma-informed care. 

Teachers at the Hiveley center are encouraged to share how they’re feeling every day on a board in the school’s office so staff know who might need extra help each day. If teachers need a break, they can go to a lounge that has snacks, drinks, and a massage chair. 

And once a month, they gather with their peers and their supervisor for hourlong reflective supervision sessions where teachers can talk through the things that are bothering them. 

Teachers say it’s made a difference. 

“It makes us better teachers because we’re not carrying it inside,” said Angela Prater, an assistant teacher who has worked at Hiveley for 16 years. “We’re able to release it.”

When she gathered the teachers of the Hiveley center for their reflective supervision session in May, Massingile touched only briefly on the subject of Mother’s Day before turning to the real purpose of the discussion. 

“Speaking of mothers,” she said. “What I wanted you guys to think about today was the mother or father in your classroom that you greet every day and you take home in the evenings. This is the mother that you hold. This is the mother that you hate to see coming. … This is the mother that you look at and smile.

“Who is that mother?” she asked. “You don’t have to say her name, but just talk about that mother.” 

She stopped and waited as the room went silent. Some of the women gazed at the floor or looked out the window until, eventually, one teacher decided to speak. She invoked a young child in her class. 

“I worry about the whole family,” she said. “There’s a lot of anger at home right now.”

A colleague of hers responded. 

“I know who you’re talking about because I think about them too, actually,” she said, as her voice began to shake and she started to cry. “I’m afraid it might turn violent. From what I’m hearing now, it’s just verbal abuse, but I’m afraid it’s going to change. Or it’s been in my head, I wonder: Has it changed and you don’t know about it?”

The child these women were worried about has a parent they fear is being mistreated by someone at home. They’ve gotten unsettling reports of the family that have trickled into the school from friends and neighbors. But they’ve been hesitant to approach the parent, worried they could say something that would result in the child being pulled from school. For some of their students, school is the safest place they can go. 

“It’s heartbreaking,” one teacher said. “We’re the outsiders looking in. We can see through the glass but can’t say anything.”

The hourlong conversation, which a Chalkbeat reporter observed on the condition that no teachers or children would be identified because of the sensitive nature of the discussion, covered a number of subjects, including the promising breakthrough one teacher felt she’d had with a difficult student.

As they talked, some women sipped on coffee. Others nibbled on snacks. 

But when the conversation drifted toward possible solutions, such as the family therapist the teachers thought could intervene with the parent they had concerns about, Massingile gently steered the conversation back to the women in the room. 

“This isn’t the place to fix it,” she told the circle, noting that Head Start social workers were already working with the family. “Part of taking care of yourself is … finding somewhere to put it and believing that what you did was good enough.”

It’s difficult to know how many schools across the country are taking steps to address secondary trauma or to actively support the mental health of educators. 

Though the federal Office of Head Start requires substantive supervision in Head Start centers and offers online resources to providers that want to use reflective supervision, it does not collect data on how many centers use these kinds of tools. 

Sarah Neil, the manager of effective practice for the National Head Start Association, which advocates on behalf of the federal program, said she’s seeing more Head Start programs taking active steps to support the emotional wellbeing of staff members. 

For now, she said, that’s mostly the larger Head Start providers that have more resources. But in the coming years, as more educators work to address the role trauma plays in students’ and teachers’ lives, she predicted more will sign on. “You’ll see that growing dramatically across the field,” she said. 

At the Hiveley center, site leader Krystle Dionise said she’s seen major changes in her school since the reflective supervision sessions with teachers began. 

She credits the program with the drop in teacher turnover she’s seen at the center. Last year was the first time that all of the teachers she expected to return for the new school year in fact returned. She’s also seen changes in her staff, she said. 

“I’ve noticed that my staff are more empathetic to each other,” she said. “If they see a staff member in the hallway, struggling with a child, having a difficult time, they’re more willing and receptive to jump right in and help. There’s more of a family we’ve created.”

Twombly, the Starfish manager of trauma-informed care, said those changes are also playing out in the classroom. 

“The classrooms look different,” she said. “They have more joy in them. The teachers are feeling more confident. More competent. More calm when they’re in there.” 

Before, teachers would respond to tantrums or behaviors such as hitting or toy-throwing with judgment, “saying ‘that kid is doing that on purpose. That kid is bad,’” Twombly said.  

Some teachers blamed themselves, thinking they weren’t doing their jobs effectively.

Now, she said, reflective supervision and other trauma-informed practices have helped reframe the problem for teachers.

“When they’re able to process what’s happening to them and understand why the child is engaging in that behavior, then they’re able to … look at it in a different way,” she said.

Shantell Buck, a lead teacher who started at Hiveley last year, said she often brings home some of the sadness that comes to school with her students.

“There are killings and shootings and things like that,” she said. “There’s a lot of community violence and there are a lot of kids who are very traumatized by the things they see in their home environments.”

Having a place to discuss all of that makes it easier for her to respond effectively to big behaviors she sees in the classroom, she said. 

“I hold back a lot of emotions to just stay strong for that child so it helps to be able to let loose with my peers and see that we’re all in the same situation.” 

Swingle, another lead teacher at the school, said she finds the sessions “comforting.”

“It feels good just to be able to say how your classroom’s been going without any judgement,” she said. “It gets a lot of frustration out.” 

Swingle talked to a reporter about reflective supervision one morning in June as her young charges ran around on the playground. Afterward, she returned to her classroom where, as she was sitting down to teach a phonics lesson, she found she needed some of the tools she gets from the sessions. 

Two children had been squabbling over a toy hammer when one of them picked it up and used it to hit his friend. Swingle rushed over to seize the hammer from the little boy, prompting him to scream. 

“I want the hammer!” he shrieked. 

She tried to calm him down, holding him and asking him to make a different plan, but he grabbed a fistful of her long hair and pulled as hard as he could.

She glanced around the room. Her assistant teacher had briefly left with another child and she needed backup immediately. She picked up the boy, who was screaming even louder than before and still pulling her hair, and carried him across the room. She picked up the phone, called the office and urgently asked for help. 

It wasn’t until the assistant teacher rushed back into the classroom and took the agitated boy out to the hall that peace returned to Swingle’s classroom. 

She then took a deep breath and composed herself. 

“You want to know why I need reflective supervision?” she said. 

She looked toward the door through which the screaming child had just been escorted, a nod to the difficult challenges she faces every day, and the compassion she needs to respond with patience and affection.

She had remained calm throughout the whole interaction and now the boy was out of her room in a safe space with another adult. 

“That is why I need reflective supervision,” she said. 

Then she went back to her phonics lesson.

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