Improving Mental Health Referrals Between Schools and Community Agencies

To the Editor: A national movement to develop expanded school mental health programs is under way. These programs augment services provided by school-hired mental health professionals and offer a comprehensive range of services to youths in special and regular education (1). Typically the programs involve close collaboration between community agencies and schools. Advantages include increased access both to and for youth and the provision of care in a natural setting (2). Preliminary findings from program evaluations have been positive (3,4). These factors, combined with a growing disenchantment with more passive service delivery approaches, have led to progressive growth of expanded school mental health programs (5).

When a student's needs cannot be served in the school-based program, the student must be referred out. Anecdotal reports highlight problems in the referral process. We attempted to better understand referral processes occurring in a school mental health program in Baltimore.

In 1996 and 1997, 12 school-based clinicians tracked all referrals they made to outside agencies. The 12 clinicians represented all those working in middle or high schools. Ninety-eight referrals were made to 33 different agencies in the city, including specialized clinics, outpatient mental health centers, hospital-based programs, and inpatient centers. The clinician making the referral rated the outcome on a 7-point Likert scale, with 1 indicating poor and 7 indicating excellent (98 ratings). When possible, the youths also rated the outcome (73 ratings) as did the parents (79 ratings).

The ratings of clinicians, youths, and parents were highly correlated (p<.001). The overall mean±SD rating was 4.7±2.08. About half of all ratings were either 6 or 7. About 30 percent of both the clinicians and the parents were dissatisfied with the outcome of the referral (a rating of 3 or less). Students were generally more satisfied with the referrals; only 18 percent gave ratings of 3 or lower.

Clinicians and parents provided reasons for their dissatisfaction with the referral. Most of the clinicians' concerns were related to problems with the services provided, poor follow-through by families, and insurance companies' refusals to cover care. Similarly, parents' low ratings mostly reflected concerns about the way services were provided and insurance-related obstacles.

Given the complexity and severity of stressors affecting inner-city youths and families, the success of referrals between agencies is essential for an effective system of care. Problems in community agencies such as long waits for a first appointment, limited appointment times, and financial barriers are clear impediments to the success of referrals. In addition, school-based programs often fail to approach referrals in the energetic, proactive style that is necessary to ensure that students follow through and connect with community agencies.

In the national movement toward expanded school mental health programs, increasing numbers of programs are offering intensive services such as medication. Obviously, providing more intensive services in schools will obviate many of the referral problems discussed here. However, many schools will not be able to provide intensive services, which points to the need for all stakeholders—youths, families, school staff, community agency staff, and community leaders—to join in an effort to develop a true system of mental health care for youths. In this work it will be important to identify and address barriers to referrals between schools and community agencies. We hope that findings from our pilot study provide some encouragement for this important work.

Acknowledgment

This work was supported by project MCJ-24SH02-01-0 from the Maternal and Child Health Bureau.

The authors are affiliated with the department of psychiatry at the University of Maryland School of Medicine in Baltimore.