Background:

Teleconsultation Pilot Program. The 2019-21 State Ominibus Operating Appropriations Act includes $1 million for the University of Washington (UW) Department of Psychiatry and Behavioral Sciences (UW Psychiatry) and Seattle Children's Hospital (Children's) in consultation with the Office of the Superintendent of Public Instruction (OSPI) to plan for and implement a pilot program of school mental health education and consultations for students at middle schools, junior high, and high schools in one school district on each side of the state. The pilot program must develop and provide behavioral health trainings for school counselors, social workers, psychologists, nurses, teachers, administrators, and classified staff by January 1, 2020. For two years, beginning with the 2020-21 school year, the school districts participating in the pilot program must: (a) in order to support school staff in managing children with challenging behavior, provide school counselors access to teleconsultations with psychologists and psychiatrists at Children's or the UW Psychiatry; and (b) in order to provide crisis management services when assessed as clinically appropriate, provide students access to teleconsultations with psychologists and psychiatrists at Children's or the UW Psychiatry.

Centers and Projects at the University of Washington. The UW School Mental Health Assessment Research and Training (SMART) Center is a transdisciplinary collaboration between faculty in the UW College of Education and the School of Medicine, including UW Psychiatry. The stated mission of the SMART Center is to promote high-quality, culturally responsive programs, practices, and policies to meet the full range of social, emotional, and behavioral needs of students.

The UW School of Medicine's Project Echo (Extension for Community Healthcare Outcomes) is a teleconsultation model designed for common diseases, like psychotic disorders, that have a high public health impact, require complex management, and for which clinical expertise is limited. Through Project Echo, local clinicians are able to videoconference with specialists in real-time.

School District Plans for Emotional or Behavioral Distress in Students. In 2014 school districts were required to adopt a plan for recognition, initial screening, and response to emotional or behavioral distress in students, such as indicators of possible substance abuse, violence, youth suicide, and sexual abuse. School districts must annually provide the plan to all district staff. The plan must include certain minimum components related to: staff trainings; communicating with students' families; and partnership development for referral of students to health, mental health, substance abuse, and social support services. The plan must also address how staff should respond to: suspicions, concerns, or warning signs of emotional or behavioral distress in students; or a crisis situation where a student is in imminent danger to himself or herself or others.

Training on Emotional or Behavioral Distress in Students. School nurses, school social workers, school psychologists, and school counselors must complete a 3-hour training program on youth suicide screening and referral every five years as a condition of certification. The content of the training is determined by the Professional Educator Standards Board in consultation with the OSPI and the Department of Health.

To receive initial certification as a teacher, an applicant must complete a course on issues of abuse. This course must include the following content: the identification of physical abuse, emotional abuse, sexual abuse, and substance abuse; commercial sexual abuse of a minor; sexual exploitation of a minor; information on the impact of abuse on the behavior and learning abilities of students; discussion of the responsibilities of a teacher to report abuse or provide assistance to students who are the victims of abuse; methods for teaching students about abuse of all types and their prevention; and recognition, screening, and response to emotional or behavioral distress in students, such as indicators of possible substance abuse, violence, and youth suicide.

Educational service districts are required to develop and maintain the capacity to offer training for educators and other school district staff on youth suicide screening and referral, and on recognition, initial screening, and response to emotional or behavioral distress in students, such as indicators of possible substance abuse, violence, youth suicide, and sexual abuse. Training may be offered on a fee-for-service basis, or at no cost to school districts or educators if funds are appropriated specifically for this purpose or made available through grants or other sources.

The Department of Social and Health Services (DSHS) is required to provide funds for mental health first aid training targeted at teachers and educational staff. The training must describe common mental disorders that arise in youth, their possible causes and risk factors, the availability of evidence-based medical, psychological, and alternative treatments, processes for making referrals for behavioral health services, and methods to effectively render assistance in both initial intervention and crisis situations. The DSHS must collaborate with the OSPI to identify ways to make the training broadly available.

Regional Behavioral Health Coordination. Legislation enacted in 2019 (i.e. Second Substitute House Bill 1216, enacted as Chapter 333, Laws of 2019), required each educational service district to establish a regional school safety center. Among other duties and subject to the availability of state funding, each regional school safety center must provide behavioral health coordination to school districts in its region. This behavioral health coordination includes: (a) providing support for development and implementation of school district plans for emotional or behavioral distress in students; (b) suicide prevention training for school counselors, school psychologists, and school social workers; (c) facilitating partnerships and coordination between public schools and existing systems of behavioral health care services and supports; and (d) assisting public schools to identify students in need of behavioral health care services and to link students and families with community-based behavioral health care services.

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Summary of Amended Bill:

The University of Washington Department of Psychiatry and Behavioral Sciences (UW Psychiatry) and Seattle Children's Hospital (Children's), in consultation with the Office of the Superintendent of Public Instruction (OSPI), must expand the telehealth training and consultation pilot program (pilot program) established in the 2019-21 State Ominibus Operating Appropriations Act through the 2023-24 school year.

Selection and Notification of Selection. As expanded, the pilot program must include the participation of the two school districts previously selected, and two school districts selected by August 1, 2020. When selecting the two additional districts, the UW Psychiatry, Children's, and the OSPI must select criteria designed to improve the significance of the information reported as described below. In addition, a school district may not be selected if it has a substance abuse treatment clinic or mental health care clinic within 30 miles of any school in the district. The selected school districts must notify students and students' families of their participation in the pilot program.

Trainings. As soon as practicable, the UW Psychiatry and Children's must develop and provide behavioral and mental health trainings to the following staff of participating school districts assigned to middle, junior high, and high schools: school counselors, school social workers, school psychologists, school nurses, classroom teachers, school administrators, and classified staff. The trainings must be customized to each school district and staff position based on the district's needs as assessed by the training providers. The training must be based on clinical protocols, including when to refer a student to the next level of behavioral or mental health care.

Teleconsultations. A school district participating in the pilot program must provide school counselors with access to telephone or televideo consultation with a consulting psychologist or psychiatrist who specializes in children's mental health at the UW Psychiatry or Children's. The purpose of the teleconsultation is for the consulting psychologist or psychiatrist to assist the school counselor with determining the behavioral or mental health services and supports needed by a student, identifying providers who deliver the needed services and supports, and, referring the student to available providers.

If identified as clinically appropriate by the consulting psychologist or psychiatrist during a teleconsultation provided under (a) of this subsection, a school district participating in the pilot program must provide students with access to televideo consultation with a consulting psychologist or psychiatrist.

Teleconsultation with school counselors or students may include crisis management services if identified as clinically appropriate by the consulting psychologist or psychiatrist.

Data Collection. The UW Psychiatry, in collaboration with participating school districts and Children's, must collect a number of data elements, for example: the number, category, and duration of teleconsultations; demographic information of students served; to the maximum extent possible, students' health plan information; and other data indicating whether the pilot program was successful in identifying, treating, and preventing student behavioral and mental health issues.

Report. By December 1, 2023, the UW School Mental Health Assessment Research and Training (SMART) Center must submit a report to the Legislature. At a minimum, the report must include: (a) impacts of further expanding the pilot program; (b) an analysis of the collected data; and (c) recommendations on eight specified issues, including training, involvement of students' families, development of a directory and reimbursement model for teleconsultation providers, liability, and funding.

In preparing the report, the SMART Center must review any evaluations of other behavioral or mental health service consultation or referral programs associated with the UW Psychiatry or Children's.

Staff Summary of Public Testimony:

(In support) The bill would help address one of the greatest challenges facing schools, which is the increase in student mental health issues and substance use disorders. Students may try to talk with friends about depression and anxiety but are often not taken seriously. Students are often left alone to deal with their mental health issues because their loved ones are dealing with their own mental health and addiction challenges. The referral and teleconsultation provisions in this bill would give students a way to reach out to an adult at the school and receive help.

The bill would allow school counselors, upon receipt of proper consent, to provide the facility and technology for students to receive needed services at no cost to the school district. It would allow private insurance to be billed and remove the transportation barrier.

Last year, the Legislature began funding a two-year telehealth training and consultation pilot program (pilot program). The training is being developed and delivered this year. Next year telepsychiatry consultations will be provided at one school district on each side of the state: Sumner and Medical Lake. Eight school districts applied for the pilot program. If this concept was taken statewide, there is the possibility that about 182 students would be referred for teleconsultation per day. Thus, the bill should just increase the pilot program to four school districts and extend the period to four years. Once the report indicates that the concept is proven, it could go statewide. This would allow time to set up the system for success.

This bill is important because it provides access to mental health services and promotes the use of telemedicine. Large school districts, with low-income populations, often do not have access to health care services, particularly because public transit is not available. Some students, especially those in small towns, do not have access to mental health or substance use disorder services. School-based programs are generally limited to students with state health insurance plans.

The bill's provisions should include all behavioral and mental health providers, not just psychiatrists and psychologists. The state needs to try creative ways to meet the behavioral and mental health needs of students. The pilot program will help to figure out how to make these models sustainable and successful.

(Opposed) None.

(Other) There is inadequate funding for mental health professionals in the prototypical school funding formula. Many schools do not have a nurse, counselor, psychologist, or social worker at all, or only have one for a short amount of time per week. There should be more access to mental health treatment through the school system.

There are some practical concerns with the bill as written. The pilot program should be expanded in number and length of time. The trainings that are going to be offered during the pilot program are what the schools districts want and will benefit from. The state does not want to inadvertently implement ineffective practices, so establishing a pilot program is important so that the resources can be scaled up practically and effectively. Telehealth care is happening outside the schools right now and the pilot program will help school districts figure out how to provide this service well.

All school staff should be trained in how to identify students with mental and behavioral health issues, but this will take time and money. Some staff already receive a strong mental health component in their preparation and certification requirements. Teacher preparation programs do not have time to add new requirements. It might be better to require new trainings for general education teachers at the beginning of the school year. There are a lot of trainings required for school staff at various stages of their careers.