The Other 60 Percent

Medicaid money a boon for wellness in schools

Most school districts have gotten used to shrinking or stagnating funding streams in recent years, but there’s at least one pot of money that’s defied that trend. Administrators across Colorado are quick to call it “amazing,” “unbelievable” and “wonderful.”

<em>                 Photo credit: Queen’s University</em>

It comes in the form of Medicaid reimbursements for therapy or personal care services provided to low-income special education students by their school districts. Regardless of whether districts choose to participate in the Medicaid reimbursement program, federal law requires them to find the money to provide special education services. Thus, districts that join the Medicaid program are able to recoup some of the money that they would have spent anyway.

The payments, which can total millions in the biggest districts, must be used for health-related expenses by law. While special education equipment or staffing certainly qualify, increasingly school districts are using the money for health and wellness efforts that touch all students.

This may mean suicide prevention curriculum, anti-bullying programs, more mental health personnel, or efforts to curb obesity. It can also take the form of health and wellness coordinators tasked with leading health policy discussions at the district level and establishing school wellness teams and initiatives. Many districts also use a portion of the money to reach out to families who don’t have health insurance, in an effort to connect them to Medicaid, CHP+ or some other form of coverage.

Cassandra Reese, the Medicaid coordinator and a school nurse in Academy District 20, said in the next couple years, “I’m hoping to see more wellness…It’s still in the toddler stages.”

She said the district has taken some small steps in that area using Medicaid funds, including handing out magnets with healthy snack suggestions to all elementary families.

Academy District 20 gave this magnet, paid for with Medicaid reimbursements, out to all elementary families.

In Adams 12 Five Star, which expects to receive about $1.2 million in reimbursements this year, there’s been a shift toward overall wellness efforts in the last couple years, according to those who run the program. In fact, earlier this month, the district filled a brand new position: Manager of Coordinated School Health.

Expanding and sustaining health efforts

Administrators in Adams 12 were chagrined when the annual KIDS COUNT in Colorado! report came out last spring. The county had fallen from 23rd to 24th in a ranking of the state’s 25 most populous counties on child well-being.

While that grim statistic helped create the momentum for a more coordinated approach to school health and the creation of the new manager position, Medicaid money gave them a way to pay for it.

As in all districts that participate, Adams 12 Five Star divvies up the money based on a five-year “Local Services Plan” created by district and community stakeholders. Among other things, the reimbursements pay for suicide prevention training, more nursing hours, outreach to uninsured students and help for students who need food, clothes or specialty items like glasses.

The reimbursements also help leverage money from community partners, demonstrating the district has skin in the game so to speak. For example, the district funds school-based mental health therapists partially with Medicaid money and partially with funds from a community mental health center.

“We’re all in it together,” said Sandra Sellstrom, coordinator of the district’s Medicaid School Health Services Program.

Denver Public Schools, which joined the reimbursement program when it started in Colorado in 1997, receives the largest reimbursement in the state: about $2.5 million last year. The district spends that money on a variety of things, including its four-member “Healthy Schools” team, which oversees district health policy, promotes use of school-based health clinics and works with individual schools on health and wellness efforts.

The district also uses a portion of the reimbursement money to advance the goals in its five-year plan of health priorities, called “DPS Health Agenda 2015” For example, to help meet one of its social-emotional health goals, the district spent nearly $18,000 last year on suicide prevention curriculum for sixth- and ninth-graders as well as staff training on the topic. Now, 22 of the district’s school psychologists and social workers are certified as suicide prevention specialists, up from one previously.

Although the district has raised $18 million to implement its Health Agenda through grants, donations and other sources, administrators say Medicaid reimbursement represents an integral funding stream, especially because it isn’t a one-time sum like some other sources.

“It’s been a very consistent and growing source of revenue for districts,” said Bridget Beatty, DPS Coordinator for Health Strategies. “It is one of the only sources that has been increasing in the last few years.”

Who’s in and who’s out

All told, 50 Colorado districts or Boards of Cooperative Educational Services, known as BOCES, are currently participating in the Medicaid School Health Services Program, which is administered jointly by the Colorado Department of Education and the Colorado Department of Health Care Policy and Financing. Reimbursements for participating districts totaled $16.6 million in 2011-12, the most recent year for which figures are available.

In general, participants include large and medium districts along the I-25 corridor, but there are a number of small, rural districts that participate as well. In addition, participants such as Pikes Peak BOCES serve more than a dozen small districts.

It used to be that almost 80 percent of the state’s 178 school districts participated in the program either individually or through a BOCES. But rule changes in 2008 changed how reimbursements were calculated, moving from a fee-for-service model to a cost-based model. The new rules, which required much more documentation, also eliminated reimbursements for non-special education services, such as bandaging a Medicaid-eligible child’s scraped knee in the nurse’s office.

The new focus was exclusively on special education services. For many small districts, particularly those that used BOCES staff not district staff to provide special education therapies, that meant fewer opportunities for reimbursement, said Jill Mathews, senior consultant for the Medicaid School Health Services Program at the Colorado Department of Education. As a result, many districts dropped out. The number of districts and BOCES participating fell from 114 in the 2006-07 year to 54 five years later.

“It’s not always worth it for the smaller districts to participate,” said Matthews.

Despite the drop in participation after 2008, she noted that the 50 current participants serve about three-quarters of the state’s schoolchildren. This year, there will be a push to attract more BOCES participants.

New rules beneficial

Although dozens of districts dropped out after the 2008 rule changes, those that stayed laud the new cost-based methodology, saying it helped produce major increases in their annual reimbursements. For example, Adams 12 Five Star has seen its Medicaid revenue double over the last five years. The reimbursements under the fee-for-service model were very low, said Sellstrom.

“It wasn’t even comparable to actual costs,” she said. “Before, you did what you could, but it was smaller in scope.”

Reese, from Academy 20, said the district’s reimbursement has increased six-fold since the district joined the program in 1997, jumping from about $97,000 to nearly $600,000 last year.

“It’s so exciting,” she said. “It’s money well worth looking into.”

Buena Vista, a district of 994 students west of Colorado Springs, rejoined the program last year after dropping out in 2010 because the program wasn’t yielding any reimbursements. In fact, the district had to pay money back at one point, said Stefani Franklin, principal of Avery-Parsons Elementary school and the district’s special education director.

After Mathews and another state administrator provided a detailed review of the new system, the district rejoined the program. Last year, the district got $40,000 in reimbursements, enough funding for a full-time nurse to cover two of the district’s four schools. Previously, one nurse was responsible for the district’s entire student body.

Franklin said of the second nurse, “One person seeing 400-450 kids. That’s a pretty important position. Every little bit helps.”

Unmet needs

A social worker in every grade? Perhaps for 10 Colorado elementary schools

PHOTO: Ann Schimke/Chalkbeat
Fifth-graders practice mindfulness at Munroe Elementary School in Denver.

Educators, parents, and social workers told of students struggling with depression, younger and younger children attempting suicide, and youths ending up in prison. A bill approved Thursday by a Colorado House committee would pay for a three-year trial to provide social and emotional help for elementary students in the hopes of addressing some of these challenges.

If approved by the full legislature and signed into law, the measure would create a three-year pilot program at 10 high-needs schools. It is estimated to cost about $5 million a year. House Bill 1017 would place social workers, counselors or psychologists in every elementary grade at the test schools starting next year.

In an impassioned presentation, bill sponsor state Rep. Dafna Michaelson Jenet, a Commerce City Democrat, said schools need more social workers “to stop our children from dying by suicide, from ending up incarcerated, from being failed by our system.”

Suicide is a leading cause of death among youth ages 10 to 24 in Colorado, and advocates of the bill said schools are often ill-equipped to deal with children suffering from trauma, bullying and behavioral challenges.

The bill was scaled back from an original version that would have cost $16 million a year. Michaelson Jenet said the nearly $5 million annual cost would be funded in part by $2.5 million from the state’s marijuana cash fund, with the rest from private foundations.

The National Association of Social Workers recommends one social worker for every 250 students, and one for every 50 students at high-needs schools.

Colorado schools don’t come close to those numbers.

About one-third of the state’s 178 school districts employed social workers during the 2016-17 school year, the most recent for which data was available from the Colorado Department of Education. Those districts represented about 89 percent of that year’s 905,000 pre-K through 12th grade students.

The nearly 590 social workers employed worked out to less than one full-time employee per 1,000 students.

Englewood’s Sheridan School District had three social workers for 1,511 students, while Yuma County had 1½ social workers for 807 students.

The two largest districts, Denver and Jefferson County, employed more than one-third of school social workers that year, with more than one social worker for every 1,000 students. Denver voters approved a 2016 tax to help pay for more social workers.

But many districts have no social workers. And most school social workers are stretched thin.

Jessie Caggiano is a social worker who serves more than 3,000 students at four high schools in Weld County.

“I’m not able to meet with students effectively on a one-on-one basis, because I’m trying to implement other services schoolwide,” she said. “I’m only at each of my schools one day a week, so I’m not able to meet their needs by any means.”

Darlene Sampson, president of the Colorado chapter of the Association of Black Social Workers, recalled working at a Denver school when a student was killed in the cafeteria.

“Many kids are carrying their trauma in their backpacks into the school,” Sampson said.

And Cam Short-Camilli, representing the Colorado School Social Work Association, said students are facing increased emotional problems at most schools. The increase in youth suicide and suicide attempts is especially difficult, she said. One Denver incident last fall attracted national attention.

“Every school district, every student is impacted, that’s rural, urban, suburban schools,” Short-Camilli said. “In the past five years, I’ve been at elementary schools, and it’s been extremely shocking. Kids at those schools, there’s an immense ripple effect.”

But state Rep. James Wilson, a Salida Republican, questioned whether the pilot program would be possible to replicate because of the high number of professionals needed.

“I’m sitting here feeling like the Grinch,” Wilson said. “I cannot bring myself to put together an unrealistic pilot. Will it really work in the real world?”

State Rep. Janet Buckner, an Aurora Democrat, also expressed concerns, but voted for the bill.

“I’m concerned how we’re going to fund it,” she sad. “The suicide rate is off the chart and our kids need so much help. I don’t think we can wait. I have a lot of phone calls and emails about this bill, people who really need the help.”

HB-1017 next goes to the Appropriations Committee before being considered by the full House, then the Senate. It is one of several measures aimed at offering help for students and their families beyond academics at public schools.

Story time

This Memphis teacher’s favorite student didn’t stand for the Pledge of Allegiance. She taught him a powerful lesson.

PHOTO: Xzavier Bonds
Daniel Warner teaches at East High School in Memphis.

When one of Daniel Warner’s favorite students refused to stand for the Pledge of Allegiance, he could feel the tension in himself rising.

It was August 2017, the first week of classes, and Warner said he knew how important setting a tone was during the first few days of school.

“Didn’t my teacher prep program teach me that I have to set high expectations in that first week or the year is lost?” asked Warner, a U.S. history teacher at East High School in Memphis. “If I don’t set those, we’re done for.”

But before Warner reacted, he said he took a few moments to reflect on what could be going through her head.

Chalkbeat TN Storytelling Event
PHOTO: Xzavier Bonds
Daniel Warner tells his story to a crowded room.

It was the Monday after a violent white supremacists rally in Charlottesville, Virginia. Stories of former NFL quarterback Colin Kaepernick were again dominating the news, as he remained ostracized for kneeling during the national anthem to protest police brutality.

Instead of punishing her, Warner said, he refocused on what she might be thinking through as a black American high schooler.

“The lesson she taught me that day was that some of the most harmful instances of school discipline happen when we are too focused on ourselves as teachers,” Warner said.

Warner was one of seven educators and students who participated in a February story storytelling night hosted by Chalkbeat Tennessee, Spillit, and The Knowledge Tree. The stories told centered around school discipline practices, a topic Chalkbeat recently dove into in this special report.

Video Credit: Gillian Wenhold, The Social Exchange. The Social Exchange is a pay-as-you can PR & content creation firm for nonprofits and responsible, women/minority owned businesses.

Here’s an edited transcript of Warner’s story. It has been lightly edited for length and clarity:

It’s a week into school in early August. And kids are just trickling into my senior homeroom mostly asleep, sitting quietly in their desk as 18-year-olds do at 7:15 in the morning…And then morning announcements come on. “Please stand for the Pledge of Allegiance.”

So I stand up, and I say, “Alright y’all, go ahead and stand up with me.” I see these seniors throwing their bodies out of their seats, trying to stand up while they are still asleep. And almost everyone stands up but one girl doesn’t…  

So, my eyes meet this girls eyes as she stays in her seat during the pledge. And I can feel the tension in me of my authority being challenged in the room. And I wonder if everyone else is looking at me, my other students. So I give her a teacher look meant to communicate, “Are you going to stand up?” And she looks at me from across the room and shakes her head and mouths, “I can’t.”

So this student was one of my best students the year before in honors U.S. History. She engaged deeply with the material and personally. She asked questions of herself, of her country, of democracy, what this whole thing is about. She processed the double consciousness she feels of being both black and American. And she did so while being kind, thoughtful hardworking. The student you think of that makes you want to cry, you love that kid so much. I wonder what’s going on, what is she thinking about…

This is a Monday and the weekend before had been the white supremacists march in Charlottesville… When she told me, that she couldn’t stand, I went and sat in the desk next to her…I asked, “What’s keeping you from standing up?”

She started by saying, “I hate,” and she stopped herself. She took a breath, calmed herself down and said, “I just can’t.” And so we just sat there for a second. I could see as I got closer to her that she was flooded with emotion and feeling something deeply. And so we let the announcements end and I tell her, “When I say the pledge I say it more as a hope and a prayer…that there would be liberty and justice for all.” She said, “Yeah, I was thinking about that,” like a good U.S. History student, but she said “things don’t’ seem to be headed that way right now…

The lesson she taught me that day was that some of the most harmful instances of school discipline happen when we are too focused on ourselves as teachers. She showed me that I was a little too focused on how I was being perceived by other students in the classroom. And that I wasn’t focused enough on her and what she might be processing. As teachers, we have all of this opportunity to escalate conflict, I’ve done it plenty of times. But we also have an opportunity to be gracious to students who are working out who they are in public…

This girl wasn’t being disengaged by saying no to me, she was being especially engaged with who she is… When we talk about restorative justice, the first step we have to take is for us as educators and adults, and it’s doing your own emotional work. And we have to ask ourselves questions about our identities. You can only lead someone somewhere if you’ve gone there yourself…

What is it about us when it sets us off when a kid says no to us? Why are we that insecure? … When we pay attention to ourselves, our emotional status, the hurt we’ve felt, the pain we’ve lived through, that is when we can begin paying attention to how formative schools are. They are spaces where folks are working out their identities in public, and that’s when you feel the most self conscious and vulnerable and in need of grace offered by someone else.

So, I hope as we talk about this, we think of ways where we can make school a space for people to be figuring out who they are and not just punished into compliance. In high poverty schools, you talk about compliance like it’s the ultimate behavior. I hope we can make schools where students can learn what it is to seek justice, even when and especially when, things just don’t seem to be headed that way right now.