Feasibility Study for Demonstration of Supported Education to Promote Educational Attainment and Employment among Individuals with Serious Mental Illness: Final Report. 5. Site Visits

09/01/2015

5.1. Introduction

In this chapter, we describe how individuals living with mental health challenges are supported as they pursue educational goals. We sought to understand how these supports are operationalized through the eyes and experiences of those who deliver these services. Individual case studies were conducted in settings in Oregon, New Jersey, and Minnesota, where the educational goals of people with mental health concerns are supported. We begin the chapter with a description of the methods used to choose the settings for study and the procedures for the site visits. A summary detailing the service structure, recruitment and engagement strategies, and successes and challenges, among other topics, is included for each setting. Following the three case studies is a synthesis of the important similarities and differences between the sites. This chapter concludes with a list of key findings that the case studies offer for the SEd field.

5.2. Methods

5.2.1. Identification of Case Study Sites

Our selection of sites was informed in multiple ways. We first searched for sites across the United States that help individuals with mental health concerns to pursue their educational goals. An initial list of possible sites was compiled from the literature review (n=10), which was supplemented with sites identified by key stakeholders during the environmental scan (n=13). These sites were reviewed by additional SEd content experts, who added to the list (n=2), resulting in a total of 25 unique initiatives.

The goal was to identify three sites for visitation. Criteria for site stratification were identified to maximize variation in the depth and breadth of the data collected across the three sites, and to highlight important constructs identified in the field of SEd as identified through the literature review and environmental scan. Primary selection criteria included: (1) having one site that targeted individuals experiencing a first episode of psychosis, a schizophrenia-related condition; (2) having one site based in a community mental health setting; and (3) having one site based in a post-secondary education setting. Secondary selection criteria included having geographic diversity among the three sites. Sites that served only a specific target population (e.g., veterans) were also excluded. In addition, environmental scan stakeholders and content experts were asked to nominate SEd programs or initiatives that were, in their opinion, exemplary, innovative, and worthy of site visitation; this resulted in the identification of 15 sites (a subset of the original 25). Sites selected for visits all received at least one nomination from a stakeholder or content expert. Investigators reviewed the remaining 15 sites and identified three that best met selection criteria.

5.2.2. Selected Sites

As a result of our stratified purposeful sampling strategy, we chose three sites for visitation:

  • Early Assessment and Support Alliance: The EASA program is a statewide effort in Oregon to address the needs of young adults, which includes educational needs. EASA focuses on individuals experiencing a first episode of schizophrenia-related conditions.

  • Learning Enhancement and Resource Network (LEARN): The LEARN program is a standalone SEd program based in a New Jersey community-based mental health center. LEARN supports individuals of any age with mental health concerns in achieving their educational goals.

  • University of Minnesota: The University of Minnesota has a campus-wide initiative to support the mental health needs of all students. Their Provost Committee on Student Mental Health has prioritized mental health and wellness campus-wide, and has created a culture of attention and resources to support student mental health.

5.2.3. Site Visit Methodology

A leadership contact person was identified at each site. Investigators emailed site leaders to describe the study and the site selection process, and to ascertain interest in hosting a site visit. Leaders from all three selected sites agreed to participate. Investigators worked with site leaders over a period of 2 months to identify visit dates, discuss key stakeholders to meet with, and work on overall visit logistics. Site leaders were sent a list of domains and questions of interest (see Appendix A) to investigators and asked to identify which stakeholders were most able to address the proposed domains/questions. Investigators had at least one telephone call with each site to discuss draft itineraries and answer questions about the research.

Site visits were conducted in April and May 2015. Two investigators visited each site, and each site visit lasted 2 days. All visits began with a discussion with the identified site leader. Investigators met with some stakeholders one-on-one while others participated in group discussions. Two sites had seven discussions each, most of which were with groups of stakeholders. One site had 11 discussions, most of which were with individual stakeholders. Stakeholders ranged from program, agency or department leaders, to front-line providers, community partners, and individuals with mental health concerns who had participated in SEd initiatives. Each site visit included one or two group discussion with individuals with mental health concerns receiving support with their educational goals; participants for these discussions were recruited by the site leader. One site included participants who were all high school and/or college aged, a second site included college aged and graduate students, and a third site included college aged and mature adult students. Discussions were audiotaped during two site visits, while one site declined because it did not have the appropriate approval. None of the discussions with individuals with mental health concerns were recorded. All sites received a stipend for their participation. Individuals with mental health concerns who participated each received an Amazon gift card. This study received an internal review board exemption.

5.2.4. Data Collection

Domains of focus for the interview protocols were derived from findings identified in the literature review and the environmental scan, and were informed by investigators' previous site visit methodologies to describe innovative programs and make policy recommendations. The interview protocol addressed domains that include: overview of the program/initiative overview; history; services offered; participation engagement; staffing; financing; evaluation efforts; service context; and successes and challenges. A separate interview protocol was developed for individuals with mental health concerns with domains that include: how they were referred; what services and supports were offered; and satisfaction with services and supports. At each site visit, one investigator led the interview while the other took detailed notes on a laptop. Investigators traded interviewing and note-taking roles throughout each site visit.

5.2.5. Analysis

Immediately after each site visit, data were reviewed and cleaned by investigators who had participated in the visit. Data from each investigator were merged into one document and coded for concepts and themes based on the site visit discussion prompts, for example, services offered, participation engagement, and staffing. Increasingly specific and narrow categories of concepts and themes were defined within this framework to condense extensive raw data and to identify common themes. From these themes, a narrative case study was written for each of the three sites. Given the diversity among the sites, some themes spanned all three sites (e.g., funding), while other themes were more specific to individual cases (e.g., relationship between SEd and SE). Each individual case study was reviewed by the identified site leadership contact at least two times. All individual site visit case studies were approved by site leadership. Investigators reviewed the individual case studies for the cross-site analysis, and developed themes regarding sites' similarities, differences, and key findings. The reliability of findings from the individual case studies is enhanced by the coding of data by multiple investigators, the comparisons of these data with findings of previous research on initiatives to support the educational goals of individuals living with mental health concerns (McIntyre, 2008; Patton, 2015), and feedback from site leaders regarding the accuracy and integrity of the individual site visit reports.

5.3. Case Studies

5.3.1. Overview of Supported Education Dimensions across Sites

Table 5-1 provides a brief overview of basic SEd dimensions across each of the three sites.

TABLE 5-1. Summary of SEd Dimensions across Sites
  EASA LEARN University of Minnesota
Setting Community mental health settings Community mental health settings 4-year university
Service approach Integrated with other young adult services Standalone service Integrated with other university services
Scope Statewide Multicounty Campus-wide
Target population First-episode schizophrenia-related conditions Individuals of any age receiving community mental health services University students
Primary staffing Occupational therapists Education coaches Varies by academic organization
Primary referral sources Hospital and outpatient mental health settings Community mental health programs and campus counseling departments Offices of disability, mental health services, and counseling
Financing State mental health block grant and state general funds; some department of VR and Medicaid funding State contract for SEd services Varies by academic organization; very limited targeted funds

5.3.2. Early Assessment and Support Alliance

Overview

Oregon has a complex set of programs and initiatives, some statewide and some standalone, which exist to support individuals with mental health conditions in meeting their educational goals. The primary initiative in Oregon that helps individuals with psychiatric disabilities to achieve their educational goals is the EASA program. EASA began as a targeted effort to prevent early trauma and disability caused by schizophrenia-related conditions. This initiative was in direct response to the Oregon Health Authority's prioritization of the implementation of evidence-based practices, and had the expressed goal of minimizing disabilities associated with schizophrenia-related conditions. EASA began in 2001 in five counties across Oregon. In 2007, a mandate from the state legislature was introduced to begin disseminating EASA services statewide. To date, EASA has 24 teams in 36 counties in Oregon, and serves the majority of the state. EASA teams are operated by community mental health centers, and some EASA teams serve multiple counties. SEd has been a part of the EASA mandate since its inception.

In July 2013, the EASA Center for Excellence was established at Portland State University's Regional Research Institute. The EASA Center for Excellence provides training, consultation, and implementation support for the EASA programs in Oregon, and for other agencies or organizations interested in using elements of the EASA program model. The Center for Excellence works with EASA programs and other partners to carry out research and build new knowledge about how best to promote positive outcomes for young people experiencing psychosis.

Oregon also has other programs and initiatives focused on SEd. In 2007, Oregon developed pilot programs funded through a state block grant in three community mental health agencies exclusively devoted to SEd. In addition, Oregon is home to a Supported Employment Center for Excellence that includes a focus on SEd.

Early Assessment and Support Alliance Approach

EASA is part of a broader state-level movement to address the needs of young adults and to invest in their specialized needs, including educational needs, at this critical developmental juncture in life. EASA is a transitional program designed to provide services and supports for 2 years. Fidelity to evidence-informed interventions is a cornerstone of EASA since its inception. EASA has several evidence-based practices in its service array including person-centered planning, cognitive behavioral therapy, and IPS. EASA's array of services are based on evidence but also driven by the unique needs of each individual. EASA's practice guidelines encourage SEd services to be provided following the same principles of care as IPS, but there is no one endorsed model of staffing or activities for SEd that is promulgated across EASA sites. Each site decides this separately, dependent on the specifics of the site. As noted by one stakeholder, "We don't have a commitment to a specific model of SEd as much as a commitment to the educational needs as identified by young adults."

All EASA supports are driven by the basic question, "What are the goals of the young adult?" It is this shared approach and philosophy that creates coherence across EASA sites and services. EASA is committed to getting young adults the help they need, as identified by them, in a time sensitive manner--there are no waiting lists for services. In addition, EASA is committed to a participatory approach with young adults, and engages them in all aspects of the work. This includes active involvement in the program from participants receiving services, participation in a leadership group for EASA program graduates, and employing staff within the EASA program who have lived with the experience of mental illness.

Services and Supports

EASA services are based on practice guidelines that build on the work of the Australian Early Psychosis Prevention and Intervention Center as well as the SAMHSA evidence-based toolkits, including multifamily groups, illness management and recovery, dual diagnosis treatment (chemical dependency and psychosis), and SE. EASA services include: outreach and engagement; assessment, diagnosis, and treatment planning by mental health professionals specifically trained in early psychosis work; education and support for individuals and families/primary support systems; crisis and relapse planning; assistance with knowing rights and available benefits; goal-setting and planning; mentoring and opportunities to meet others; independent living skill development; occupational therapy; resource brokering and advocacy; support for vocational and educational settings; group and individual counseling; and medication support.

Specific to educational goals, EASA uses a "whatever it takes" approach to providing services and supports to young adults. As such, there is no manualized set of services; supports often include, but are not limited to, help with setting educational goals, helping develop organizational skills, learning about campus accommodations and policies specific to psychiatric disabilities, working with financial aid, and registering for classes. Supports specific to organization, time management, and self-care were mentioned frequently by both EASA staff and participants. All supports are tailored to the individual needs of the individual participants, and may change over time as the needs of the participants change. EASA staff will often initially assist participants with an educational activity (e.g., registering for classes), then work with participants to help them complete the task independently.

Stakeholders report that school officials are excited about EASA, as it provides a set of services and supports that are not usually offered in post-secondary education settings. EASA team members interact frequently with the campus Offices of Disability Services and Offices of Counseling. EASA teams learn all the processes of how to access campus-based services and accommodations; and although being involved in EASA does not allow for participants to be fast-tracked for accommodations, EASA staff familiarity with school procedures and rules allows services to be streamlined for EASA participants. In some cases, colleges have granted administrative exceptions for allowing participants to return to campus contingent on their being engaged with EASA.

Participant Identification/Engagement

From July 2013 through June 2014, 433 individuals participated in EASA, with 38% under 18 years of age. Forty-one percent of EASA participants were in school at some point during their engagement with EASA. For participants 18 years of age or older, 57% had 12 years of education, while 29% had less than 12 years and only 14% had more than 12 years. Data from 2008 to 2014 suggest that the majority of EASA participants are White (66%) and male (73%). Thirteen percent identify as Hispanic, and 8% as Black/African American. Approximately 60% of EASA participants are on Medicaid. The majority of EASA participants (over 90%) have strong family support, and many EASA participants are still living at home. EASA participants come from all income levels.

EASA referrals come from a variety of sources, with most originating from psychiatric hospitals (28%), outpatient mental health providers (23%), emergency departments or crisis centers (13%), or family (6%). Approximately 42% of all EASA-referred individuals have been hospitalized within the previous 3 months. Occasionally there are self-referrals or referrals from other students, but individuals experiencing psychosis are less likely to self-refer.

Once a referral is made, an EASA clinical intake screener will collect information on why the referral is being made, and assess if the individual meets EASA criteria. EASA criteria include being between the ages of 15 and 25 (some programs may accept individuals as young as 12), and having or being at risk of a first episode schizophreniform or bipolar spectrum psychosis. If eligible, the intake screener will reach out to the young adult and schedule an in-person meeting. After initial contact with EASA, the first task is to conduct a needs assessment to identify goals. Younger EASA participants are usually in school, while older participants are often interested in returning to school.

EASA staff members do not assume that individuals will be ready to begin active engagement with EASA subsequent to the initial meeting. The intake screener will try to learn a bit about the young adult before the initial meeting, to make the first conversation informed by issues that are of specific interest to that young adult. The screener will also try to arrange to be introduced to the young adult by a person who is trusted by that young adult. Part of the initial assessment will include a safety assessment, a strengths assessment, and an overview of family supports and resources. Much of the early work between EASA and a young adult focuses on facilitating family support and engagement.

EASA uses a proactive engagement strategy, and EASA team members spend a substantial time in the community educating people about early signs and symptoms of psychosis, as well as identifying the risk factors for a first episode. In recent years, EASA has shifted its emphasis from being a "first episode" program to also being an "at risk of first episode" program. Outreach efforts focus on hospitals, community mental health centers, and faith communities. EASA also targets 4-year and 2-year colleges, community colleges, high schools, and the occasional middle school. EASA is engaged with approximately 300 schools across Oregon. In recent years, outreach efforts have extended to include property management companies who are often housing young adult college students), high schools, and, in some targeted communities, middle schools. Students may transfer between EASA sites as they move between communities for school or other reasons.

Staffing

EASA team membership varies across sites. At a minimum, all teams include a lead clinical case manager (a MA level therapist), a psychiatrist or psychiatric nurse practitioner, and a SE specialist. When EASA was first launched, the SE specialist would focus on both supporting employment and educational goals. In an effort to follow evidence-based practice guidelines and IPS fidelity standards (that are tied to funding), SE and SEd tasks were separated.

The majority of teams also have an occupational therapist. For most teams, it is the occupational therapist who leads the education support efforts with participants. The skill set of the occupational therapist is particularly valuable; this professional specializes in assessing barriers to the ability to learn, examining how cognitive information is processed, conducting environmental assessments, and identifying sensory needs. In Oregon, occupational therapists are recognized as qualified mental health professionals and are able to bill third-party payers; this is not the same in other states.

There is currently only one EASA site with a dedicated SEd specialist. Current hiring guidelines suggest that a SEd specialist have a BA degree, but not necessarily a clinical background. SEd specialists may have experience in special education or rehabilitation. The most important characteristics of the SEd specialist are the ability to understand the learning experience of young adults with educational goals and the ability to work as part of a team.

The use of peer support staff is not uniform across EASA sites, or in the delivery of SEd supports. There are some peers engaged in SE services, as there are three community mental health agencies across the state that have some state funding to hire peer support specialists. There is, however, an interest in thinking more about the role of peers in EASA teams, and a desire to operationalize their essential tasks.

EASA strive for a 1:10 staff team/young adult ratio. Team membership in rural counties is often hampered by a limited workforce and shortage of specialized practitioners, particularly occupational therapists.

Financing

When EASA first began in 2001, it was financed through a one-time appropriation of locally managed Oregon Health Plan (Medicaid) dollars set-aside for prevention activities and reinvestment. These funds were awarded by Mid Valley Behavioral Health, an Oregon mental health managed care entity, to fund EASA in five community mental health agencies. From 2002 through 2010, EASA relied in part on federal block grant and private foundation funds to support the clinical services in the original five counties. In 2007, the Oregon legislature appropriated ongoing state General Fund dollars directly from the state legislature to support statewide dissemination of EASA. In 2015, there are approximately $6 million devoted to staffing and delivering EASA, which includes state general funds, Medicaid reimbursement dollars, some private insurance payments, and a small amount of VR funds. For the most part, block grant and general funds are used to fund the array of SEd supports. Medicaid can be used to cover services such as case management and skills training. Private insurance, which is the least used funding source, is used to pay for psychiatry and some individual therapy. EASA is committed to providing an equal level of service regardless of the insurance status of its participants.

Some counties have been able to use state VR dollars to fund SEd services. In Marion, Yamhill, Polk, and Linn counties, EASA teams each have a small caseload of young adults who are receiving educational supports that are funded by the Office of Vocational Rehabilitation. The hope is that this can lead to a statewide dissemination of career-related and educational supports through a matching agreement for funding with VR.

With Medicaid, there is a state statute that mandates a SE billing code. This billing code is specifically tied to use of and fidelity to IPS. Oregon is in the process of creating a modifier for the SE Medicaid billing code, which will allow for SEd activities that are part of SE and IPS to be billed accordingly. Stakeholders were clear to state that while this will not increase the dollar amount available via Medicaid for SEd (as these are allocated at the local level), it will "legitimize" the delivery of SEd services, and "give permission" to team members to do SEd work and implement SEd best practices not articulated in the IPS model. It is also possible that the relative allocation of Medicaid funds for SEd may change (i.e., increase) moving forward. Medicaid in Oregon is distributed through local Coordinated Care Organizations, which use varying payment methodologies that are locally determined.

Block grant and state general funds were generally felt to be reliable funding streams since EASA began in 2001. Connecting SEd to IPS, which can use Medicaid, state general funds, and VR dollars, was seen as a potential avenue to increase access to funding for SEd. This, however, is fraught with challenges as fidelity to IPS is tied to funding, and integrating SEd into IPS creates challenges for meeting IPS fidelity standards.

Early Assessment and Support Alliance Sites

While all EASA sites share a set of core principals and philosophy, sites vary in staffing levels, organizational composition, funding streams, and strategies for supporting educational goals. Below are brief descriptions of various EASA sites that explain these variations.

  • Lifeworks NW: Lifeworks NW is a community mental health agency located in Washington County, Oregon. Lifeworks is unique in that it is the only EASA site with a dedicated SEd Specialist. The SEd Specialist works half time with the EASA program and half time with the agency's transition-age youth program. This team has identified SEd as a priority. At Lifeworks NW EASA, there are seven FTE positions shared among 12 staff members, serving 52 clients. EASA funding is valuable not only for its monetary contribution but for the flexibility to pay for services and supplies that cannot be funded in other ways.

  • Marion County Children's Behavioral Health: In Marion County, EASA is located within the County Department of Children's Behavioral Health, and is colocated with the agency's transition-age youth program. This is somewhat unique, as the majority of EASA sites are located in adult mental health settings. Marion County EASA has 63 young adults, of which 5 are in high school. Approximately half of the 63 receive some sort of educational support.

  • Yamhill County Adult Mental Health: In Yamhill County, EASA is located within the County Department of Adult Mental Health. The Yamhill EASA team uses an occupational therapist to take the lead on educational pursuits. In addition, a peer support specialist is part of the EASA team, and is particularly important for helping young adults meet their educational goals. Neither the occupational therapist nor the peer support specialist are full time with EASA. Yamhill County is a smaller county and its EASA serves approximately 8-9 young adults.

    Yamhill County has a long history of being proactive in developing vocational supports for first-episode young adults, and as such has one of the strongest relationships across EASA sites with the Department of Vocational Rehabilitation. A VR counselor is colocated with Yamhill County EASA to streamline referrals and expedite eligibility into VR supports. Working with EASA has required VR to engage and deliver services more quickly, and to be more flexible with their protocols, including promoting educational pursuits as part of a larger career pathway. VR stakeholders emphasize the importance of colocation with EASA--having a counselor on-site with an EASA caseload--but also acknowledged that it was a culture change, and were not sure if all VR stakeholders had "buy in" with this way of providing supports.

Early Assessment and Support Alliance Innovations

EASA continues to grow and evolve to address issues of changing young adult needs. EASA is involved with two efforts that expand and/or modify supports for EASA-involved young adults that are specifically related to supporting educational goals. These efforts are described below.

  • Project Access: Project Access is a collaborative pilot in four counties (Marion, Yamhill, Polk, and Linn) with the state Department of Vocational Rehabilitation that was developed in 2010 to expand career-oriented services beyond EASA's 2-year cap on services. Project Access provides longer-term support of EASA participants 15 years of age and older, and extends eligibility to include EASA participants up to age 30. Project Access was initially funded through stimulus dollars but is now funded by VR. Project Access is designed to provide individualized supports based on an individual's developmental stage. Services can include career exploration, school search, school retention, career-related activities, job search, and job retention. Using a case management approach, individuals work with Project Access staff on general career exploration, identify the types of jobs that are appealing to the participant, and determine what kind of education is needed to help achieve the articulated goals. Staff members support students through school and job searches and school and job retention, in addition to helping to secure resources such as financial aid and transportation. The pilot sites also use peer-based care.

  • Youth Hubs: EASA Youth Hubs is a pilot project affiliated with four EASA sites (Lane County, Jackson/Josephine Counties, Multnomah/Washington/Clackamas Counties, and Deschutes/Jefferson/Crook Counties) that expands eligibility beyond first-episode to include a range of significant mental health conditions. Youth Hubs are loosely based on an Australia model called "Head Space," an integrated transition-age youth model that provides preventive and early intervention services for a variety of mental health diagnoses, as well as other age-specific supports. Youth Hubs serve young adults aged 15-24 who would normally be screened out of EASA. This program began in 2014 and is funded by the Oregon state legislature through the state general fund. In addition, some Medicaid dollars are used to cover services such as case management, psychiatry, and counseling. Youth Hubs provide individualized services and supports, including supports specific to educational goals; however, no singular model of SEd is articulated.

Performance Measurement and Outcomes

All EASA sites collect data quarterly on referrals, intakes, and outcome review forms. Sites have recently begun to submit data through state-level Measurement and Outcome Tracking Systems. With Project Access, quarterly data are reported to the state Department of Vocational Rehabilitation, including information on school programs, start-date, full-time or part-time status, end date, and reason for completion with the program.

Within the standalone SEd programs, most continue to collect the data on the outcomes tracked during the original grant period, even though there is no requirement or funding tied to these data. These outcomes include number enrolled in school, number of credited registered for and completed, number of individuals who had contact with a SEd specialist, number of students who graduated, and gender, age, and drug and alcohol use status.

Additional Supported Education Efforts

  • SEd Pilot Programs: In 2007, SAMHSA Mental Health Block Grant funding was awarded to three community mental health agencies to start three pilot programs exclusively devoted to SEd. These programs were housed at Cascadia Behavioral Care in Multnomah County, LifeWorks NW in Washington County, and Options of Southern Oregon in Josephine County. The pilot programs ran for 3 years, and were open to any publically funded individual in the mental health system of any age. Block grant dollars were supplemented by a small amount of county funds and by Medicaid, which was used to bill for case management and skills training. Since the block grant ended 3 years ago, Medicaid and county general fund dollars have been used to sustain funding. These programs often run at a deficit.

  • Jackson County: A fourth standalone SEd program was introduced in Jackson County in 2014. It employs one SEd specialist, is located in three schools, and currently serves 22 students. This program is funded through SAMHSA federal block grant dollars. The sustainability of these block grant dollars is uncertain. This program uses an adapted version of the University of Kansas SEd fidelity tool (Manthey et al., 2012a) for SEd. The program has received positive feedback from students. It is unclear how it will integrate with EASA, which recently began in Jackson County.

  • Oregon Supported Employment Center for Excellence: Created in 2008, the center is part of the larger focus in Oregon on Supported Employment, and provides technical assistance to SE providers, conducts fidelity reviews, collects outcome data, and educates and advises policy makers. The center does address issues of SEd, identifying it as a promising practice, and builds on the SEd principles developed by Karen Unger for SAMHSA.

Integration of Supported Education and Supported Employment

SE is part of the array of services provided through EASA, and in many ways has been the gateway for SEd throughout the state. EASA uses the IPS employment model and its eight principles of IPS as a frame for SEd. IPS is available to individuals of all ages in most counties throughout Oregon. IPS services are funded through the state general fund (where EASA is being delivered), Medicaid, and a small amount of VR dollars. Use of the SE billing code for Medicaid requires meeting IPS fidelity requirements.

There is no single identified strategy for integrating SEd into IPS. When EASA began, SEd supports were delivered by a combined SE and SEd Specialist. The emphasis on IPS fidelity has required these positions to become separate, to allow a targeted focus on SE. The State of Oregon requires participation of EASA sites in fidelity reviews by the Oregon Supported Employment Center for Excellence using the Dartmouth IPS fidelity tool. In order to bill the SE code, sites must pass fidelity. The fidelity tool and process strongly emphasizes job search over education-related activities; if EASA teams spend very much time on education their IPS fidelity scores will generally be lower. This can result in a disincentive to support educational goals. However, most young adults using EASA services have educational goals, and see school as a path toward securing employment and establishing a career. EASA staff members are constantly struggling to balance these competing demands.

Successes and Challenges

Stakeholders identified both challenges and successes in the efforts to address the educational needs of the young adults at risk for or experiencing first-episode schizophrenia-related conditions.

Successes:

  • Having state-level champions endorsing the importance of addressing educational goals in this population.

  • Creating the expectation within EASA that school and work are immediately supported, with no waiting for services to be delivered.

  • Using a transdisciplinary model of service provision, under which multiple EASA team members are addressing multiple domains of young adult functioning and goals, including supporting educational goals.

  • Creating consistent and reliable relationships between young adult participants and EASA team members, with a focus on educational goals. EASA team members serve as mentors and coaches, and can normalize the experiences of young adults.

  • Educating young adults and family members on what is most helpful to young adults in achieving their educational goals, and providing supports.

Challenges:

  • The continual push and pull between SE and SEd: The emphasis on IPS fidelity from the state, which is directly tied to funding, does not always encourage supporting educational goals.

  • The focus in Oregon on implementing evidence-based approaches while also needing to meet the needs of young adults, in that what young adults often need may not fit into an evidence-model of care.

  • Limited resources: Most EASA teams do not have a dedicated SEd Specialist, and there are challenges in identifying and retaining a specialized workforce, especially in some of the more rural parts of the state.

  • Metrics collected by Oregon's Community Care Organizations do not include any focus on education and/or school.

Participants' Stories

Seven young adult EASA users participated in group interview settings--four in one interview and three in another. One had graduated from EASA services (and was currently a part of the EASA Young Adult Advisory Committee), and six had been with EASA anywhere from 6 to 20 months. Participants ranged from 17 to 24 years of age; half were men and half were women. Most EASA participants came to the program through inpatient hospital settings or family referrals. Most were in college when their first episode occurred, resulting in withdrawing from school. All participants had educational goals that were addressed and met through working with EASA.

Almost all participants entered EASA with a significant educational goal. For most, it was the desire to reenroll in college and pursue a degree. Participants described a range of supports provided by EASA that included, but were not limited to, help registering for classes, working with college offices of disability services, connecting to community mental health providers, finding summer employment, completing financial aid forms, researching scholarships, and providing reminders about appointments and schedules. Participants were especially grateful for the engagement with family members, both for providing education about mental illness and first-episode events, and for problem-solving with family members when challenging situations arose, for example, working with financial aid forms. Participants were particularly grateful for the flexibility of EASA staff and their willingness to meet them at times and locations convenient to their school and work schedules.

Participants stressed the importance of their relationships with EASA team members. One participant noted, "The SEd Specialist is like a buddy. He treated me with a lot of caring and kindness." Another noted the value of connecting with EASA team members: "You can really trust them and talk to them not just about educational or employment goals, but also about life and how things are going." Participants highlighted and appreciated the holistic focus of EASA, compared with a more medical model approach in a hospital setting, and the emphasis on communication and creating relationships with EASA team members. EASA participants were concerned, however, about the time limitation of 2 years for using EASA services. Overall, participants were very satisfied with their experiences with EASA. As one participant noted, programs like EASA "make it possible to progress out of psychosis and be independent again."

5.3.3. Learning Enhancement and Resource Network

Overview

LEARN of northern New Jersey provides services for adults with a psychiatric disability residing in four counties. LEARN is situated in a community-based mental health center. LEARN provides services to students across ten community and 4-year colleges and technical schools in the LEARN catchment area. LEARN coaches are trained to develop relationships with higher education staff with whom they interact. Services are provided to adults who wish to pursue higher education. LEARN provides information, resources, and support to help program participants gain access to post-secondary, vocational, and certificate programs. LEARN of northern New Jersey is administered by the Saint Clare's Health System, Behavioral Health Services in Denville, New Jersey.

The goal of LEARN is to create a climate of encouragement and success while assisting students in completing their course of study. LEARN helps with the educational enrollment process, connection to educational resources, and assistance in finding financial aid, grant, and scholarship opportunities. Educational coaches assist with the development of learning skills and provide ongoing assistance and support throughout the educational experience.

LEARN offers SEd as a standalone service that is administered through a community mental health agency. Its model is derived directly from principles of psychiatric rehabilitation, where skills are taught and supports are provided so that individuals obtain valued social roles by meeting their chosen goals in their chosen environments.

Services

LEARN provides a highly detailed and systematic set of services. All students are assessed for their academic readiness, following the trans-theoretical model of behavioral stages of change. LEARN uses a template to categorize whether the student is at low, medium, or high levels of change, and will tailor the services accordingly. For example, coaching for students at low levels of academic readiness will involve providing hope and instilling confidence, while clarifying the requirements of being a student. Moderate-level students will explore student loan forgiveness (if needed) and using a pay-off matrix to clarify goals. Actions for students at a high level of academic readiness may involve linking to on-campus supports and exploring intersession employment opportunities.

Saint Clare's also uses a "Comprehensive Plan of Care" form to clearly state a student-identified problem, related student goals and objectives, the LEARN intervention that should be applied, and target and achieved dates of goal completion. For example, a student may profess educational stress with difficulty meeting deadlines. One goal may be to make big assignments manageable by breaking long-term assignments into shorter steps. LEARN staff may also work with students to strategize about how to minimize distractions.

LEARN uses a variety of developed and tested tools. These include "Wellness in Eight Dimensions" by Peggy Swarbrick; a variety of smartphone applications such as "PTSD Coach" and "Exam Support"; a problem checklist for students that covers issues in 13 dimensions (e.g., self-care, communication); and an "Academic Wellness Plan and Crises Plan" based on Copeland's Wellness Recovery Action Plan.

LEARN's model of service delivery uses the Boston University framework of "Choose, Get, Keep" (Danley & Anthony, 1987). This means services are provided throughout the course of initial career planning, through educational application and enrollment to matriculation, until educational goal completion. Services are designed to assist with all these phases and so may, for example, provide connecting to resources that can assist with defaulted student debt. LEARN also may assist with developing a plan for dealing with prior failing grades, acquiring medical leaves of absence, and ongoing time management and study skills. LEARN stresses concrete skill development to address problems. For example, difficulties with time management are handled by developing a "time budget" with clear demarcation for periods of study, sleep, socializing, and library time. Memory and organizational difficulties are handled with concrete organizational tools, such as the use of planners, calendaring, and task prioritization.

LEARN emphasizes the rehabilitation aspect of SEd. This means that rather than just doing something for the student, (e.g., talking to a professor on the student's behalf), LEARN emphasizes teaching the inherent skills. Students interviewed seconded the assertions that LEARN coaches teach skills so that students can apply learned skills to new settings such as employment.

Importantly, unlike SE, SEd at LEARN is time-unlimited. Services will continue throughout an educational career, even through graduate work. Services continue despite interruptions in college careers. Students can leave and return to LEARN services over the years. Similarly, there is varying level of intensity according to student need. Staff members note that some students need a small amount of guidance or information, while others need ongoing and regular involvement. Services can wax or wane according to student need and preferences. LEARN is also community-based; Coaches travel to meet students in the community and on campuses. Most coach time is spent in the community.

  • Coordination of SEd with Related Services: The LEARN team is a standalone support service. Referrals will be made to other services as needed (mental health, substance abuse, etc.), but achieving education outcomes is the sole focus of this service. LEARN coaches will refer and interact closely with other service providers. For example, they work closely with college mental health counselors and will do joint case reviews. However, these individuals are not specifically a part of an interdisciplinary team. Saint Clare's has participated in the National Institute of Mental Illness multisite study using interdisciplinary teams for first-episode psychosis and noted that this kind of closely knit team was very beneficial. However, a concern was noted about integrating SEd with SE. The Team Leader noted that due to SE's longstanding history in the state, when these two services are integrated, SE will always take priority over SEd. She noted the importance of having dedicated time for SEd, because without it, SEd "will take a back seat."

    LEARN staff are encouraged to form collaborative, mutually supporting relationships with college personnel and service directors. LEARN staff noted that targeting counseling and disability services staff for an initial contact to explain services is a successful strategy to achieving buy-in with colleges. Issues to be worked out with schools include access to school computers or log-in, office space (especially for meetings with students), permission to park, and credentials for security checks such as staff IDs. Case reviews with mental health counselors has been one successful strategy to building collaborative relationships around the program in for individual students.

Recruitment/Engagement

LEARN currently serves nearly 80 students. Students are referred from a variety of sources but especially mental health counseling departments of colleges and the mental health centers of the four counties served. LEARN also markets its program at college fairs. LEARN does not report particular difficulties with engagement; staff note that the clear focus of the service on students' identified academic challenges is motivating. Also, some note that the youthfulness of the education coaches, and the ability to relate personally to having academic goals, aid student engagement.

Staffing

The LEARN team is composed of education coaches (BA level); educational specialists/clinician (MA level); and a team leader (MA level with clinical supervisor's license). Due to a large geographical catchment area (four counties), some coaches are assigned specific areas or are assigned to a specific college. Coaches travel and conduct community-based visits with students and school personnel. There is a 25-student caseload size, and visit frequency is determined by need and preference. Some students on the caseload will need infrequent contacts, such as at exam time only. LEARN managers stress staff team building, because this work can easily lead to burnout. The team meets weekly and receives individual clinical supervision from the Team Leader.

Presently new LEARN staff receive 4 days of training from a state contracted trainer from Rutgers University, Integrated Employment Institute, Department of Psychiatric Rehabilitation and Counseling Professions. New staff will be shadowed by experienced staff at Saint Clare's. Staff participate in quarterly "roundtables" group training sessions and ongoing technical assistance. LEARN staff stresses that coaches need detailed knowledge that is specific to the many school settings they encounter, for example, when is the drop/add period over.

As Saint Clare's has had an existing SE program, SEd was easily added to the service array. There are important similarities in the two services, and coaches from one may help the other during busy periods. Hence, staffs and coaches are cross-trained in SE and SEd. The two services together are called career services.

Financing

LEARN of northern New Jersey is a contracted provider of SEd services funded by the state of New Jersey Division of Mental Health and Addiction Services (DMHAS). SEd is funded by the state as a standalone service. Community agencies bid on contracts with the state to deliver SEd. Through four contracted providers, SEd services are available in nearly all counties of New Jersey. The program for this site visit is housed in a hospital-based health care system (Saint Clare's) that delivers an array of outpatient behavioral health services including Assertive Community Treatment Program teams, SE, and partial hospitalization.

Before the LEARN initiative, New Jersey had a state-sponsored SE program. Members of the New Jersey DMHAS, some of whom were alumnae of the Boston University Center for Psychiatric Rehabilitation, designed a SEd service based on the "Choose, Get, Keep" model. An Request for Proposal (RFP) was released by the DMHAS in 2007. Saint Clare's bid and was selected, along with three other agencies. The initial RFP intended that SEd programs would be awarded to and housed within existing New Jersey SE programs. Saint Clare's had an existing SE program that was expanded to include SEd services. A contract was released in 2008 to SE programs originally at $137,000 (each) a year. The contract for SEd services has never yet been recompeted. Each year, Saint Clare's resets its contract for the numbers of students they will serve. Services are billed to the state for every 15 minutes of staff time (rates do not vary by whether the coaches or the team lead provides the service).

Presently, Saint Clare's does not bill private insurance for SEd services as these services are not covered. When the program was initiated the costs were covered 100% by DMHAS. However, state funding has not changed with increased cost of living expenses of providing services. The hospital provides additional funding to offset general and administrative costs. Individuals enrolled in LEARN may be eligible for additional funding through the Division of Vocational Rehabilitation. This funding can be used towards student tuition.

Performance Measurement and Outcomes

LEARN at Saint Clare's has a highly specified quality control and tracking effort for SEd services that is reported quarterly. Among the measures are: numbers of individuals (i.e., served, received, and completed educational readiness services, enrolled in schools, graduated, and linked to employment); numbers of educational outcomes (courses enrolled in, courses completed, diplomas or certificates awarded); service utilization (hours of educational readiness activities, hours of educational coaching, hours of consultation to schools); and client satisfaction. Findings show very high ratings of satisfaction and 200-300 courses satisfactorily completed per year across all participants. Since July 1, 2011, LEARN of northern New Jersey has served 306 clients who have passed 1,218 courses and earned 51 degrees and certificates including AA degrees, BA degrees, and MA degrees.

Successes and Challenges

Stakeholders identified both challenges and successes at the LEARN program in helping participants achieve educational goals across the age spectrum and at different points of college careers.

Successes:

  • Developed a comprehensive and highly specified approach to helping participants and students.

  • Uses various career tools to help participants discover their strengths and interests and to determine what educational and career paths best suit them.

  • Providing time-unlimited services that support students throughout their education; participants received the education they needed to move into the primary labor market, from certificate programs to college degrees, or just a few classes to brush up on necessary skills.

  • Forged a close working relationships with several nearby colleges.

  • Outcomes demonstrate a successful program using normalized and demanding standards for academic achievement (certificates, credits, and degrees).

Challenges:

  • Difficulty in efficiently staffing a community-based service involving multiple college campuses.

  • Providing rapid supports to students before challenges turn into crises.

  • Finding sources of funding for students to go to school.

  • Helping students integrate socially on campus.

Participant Experience

Two groups of LEARN participants were interviewed. The first received behavioral health services from Saint Clare's and included people of both traditional and nontraditional student ages. The second was a group of young people who were students enrolled at Ramapo College. In the interviews, the services received by participants were in accord with how those services were described by LEARN staff. Students noted receiving help with time management, organizational skills, coping skills (e.g., using mindfulness exercises to cope with anxiety); help with acquiring accommodations, dealing with prior educational problems such as defaulted loans, reenrolling after failures, or applying for financial aid. Students reported that LEARN coaches will check in on how students are doing and offer concrete help with understanding assignments or reviewing papers. The students seconded what was reported by staff, that LEARN does not "do it" for the students, but rather that they help the students with issues so that they learn how to handle problems on their own.

Participants were nearly unanimous in their praise for LEARN coaches and for their experiences with LEARN. Students noted that coaches were very patient, kind, and responsive. They described having open and honest relationships with coaches, that coaches were "there for them." They appreciated that coaches would come to campus to meet and pick them up from their homes for an appointment if needed. Students noted differences between what they got from college counseling and what they got from LEARN. As one said, "I felt LEARN really was addressing more of what I needed help with at the moment, and this is different from what I got from the counseling center. It doesn't take the place of counseling."

5.3.4. The University of Minnesota

Overview

The University of Minnesota is the largest post-secondary education system in Minnesota, with over 62,000 students across five campuses and 48,000 on the flagship campuses in the Twin Cities. Over the last 15 years, the University of Minnesota and its leadership have experienced a paradigm shift in thinking about mental health, and have put mental health and wellness at the forefront of the conversation about how to support students in their education as well as their life goals. Although the university does not have an identified SEd program per se, it has instead created a culture of understanding and support around mental illness and mental health that pervades all levels of university organization. As such, the university has many different initiatives that work collaboratively to address the mental health needs of the students, faculty, and staff on campus. These efforts have evolved over many years, and have involved multiple players from across the university. The result is a campus where student mental health and well-being is very much part of the day-to-day conversation about supporting individuals in their academic pursuits, and where the experience of mental health challenges is normalized for students, faculty, and staff alike.

Creating the Blueprint for Addressing the Mental Health Needs of Students

While many campus organizations recognized the challenges that mental health concerns presented to the student body, it was the University Disability Resource Center (DRC) that originally proposed to examine barriers for college students with mental health disabilities. This focus came about because the single largest group served by the DRC was that of students with psychiatric disabilities. In 2001, the DRC leadership applied for and were awarded a Department of Education Fund for the Improvement of Postsecondary Education (FIPSE) grant. The Needs Assessment Project: Exploring Barriers and Opportunities for College Students with Psychiatric Disabilities grant allowed DRC investigators to visit 13 college campuses across the county and conduct focus groups with students, faculty, and campus and community mental health providers to understand the gaps in existing mental health supports and services in campus settings. Additionally, investigators used focus groups to explore and identify potential mental health strategies that could reduce or remove the gaps and barriers identified.

The final FIPSE report included an executive summary (available at https://diversity.umn.edu/disability/educationandtraining) with detailed recommendations to remove the barriers associated with student mental health issues. Key strategies included increasing awareness on campus, decreasing stigma, fostering effective referrals and, most important, clarification, coordination, and communication among key university stakeholders. After the grant ended, a core set of university staff remained committed to supporting student mental health across the campus. This group continued to meet informally, to strategize about how to actualize the FIPSE recommendations. Over time, this group came to the attention of the Office of Student Affairs, which in turn brought the group to the attention of the Provost. A meeting with the Provost was held, where the FIPSE recommendations were reviewed. Stakeholders involved in the meeting with the Provost reflected that the keys to their success in securing the Provost's support were: (1) having data that quantitatively demonstrated the challenges and gaps; (2) providing a set of recommendations for action; and (3) gathering a group of partners interested in collaborating on promoting student mental health. The meeting resulted in the formation of the Provost's Committee on Student Mental Health, as well as some small seed money ($10,000) to support the Committee's initiatives and infrastructure. This seed money comes from a University contract with Coca Cola to sell only Coke products on campus: part of this contract provides the Office of Student Affairs with funds to distribute to student related activities.

Provost's Committee on Student Mental Health

The Provost's Committee on Student Mental Health was established in 2005 with the goal of changing the overall outlook on mental health at the University of Minnesota. Whereas mental health had historically been viewed as a private issue where students were solely responsible for finding help for themselves, the Provost's Committee pushed to address mental health as a campus-wide, public health issue, with the entire community working together to provide support. The four main goals for the Provost's Committee are to: (1) raise awareness about issues related to student mental health; (2) effect policy change; (3) improve conditions on campus for students with mental health conditions; and (4) serve as a model of collaboration for the campus and other universities.

Currently, the Provost's Committee contains 22 members, each of whom represents a distinct part of the University of Minnesota and Twin Cities community. Membership includes individuals from the Athletics Department, the Boynton Mental Health Clinic, the Office of Student Affairs and DRC, the Academy of Distinguished Teachers, the Chief of Police and Public Safety, the Center for Teaching and Learning, the Graduate and Professional Student Assembly, the Office of eLearning, the Parent Program, the Department of Psychiatry, Housing and Residential Life, the Office of Equity and Diversity, the Women's Center, the Student Counseling Center, and student members of Active Minds. Current cochairs of the Provost's Committee represent the DRC and the Boynton Mental Health Clinic.

One of the first and largest projects of the Provost's Committee was to develop a web site dedicated to student mental health. Launched in 2006, the web site provides mental health information and resources related to the University of Minnesota-Twin Cities campus, for students, their parents, faculty, and staff. The site (http://www.mentalhealth.umn.edu) contains information for crisis services, essential numbers to call for information about mental health, events on campus that raise awareness, and details about available mental health and stress management resources.

The Behavioral Consultation Team (BCT) is another initiative from the Provost's Committee that was created in response to the Virginia Institute of Technology shootings. The BCT provides coordinated advice and response to students at risk of harming themselves or others. The BCT is available to students, staff, and faculty for confidential consultation between 8:00 a.m. and 4:30 p.m., Monday through Friday. Once contacted, the BCT will use a team approach to determine the best way to respond to the situation. Minimally, the BCT will keep track of contacts to identify areas or people of concern and to ensure process and professional protocols are used.

Another project of the Provost's Committee is a suicide prevention initiative. A student Provost's Committee member introduced a concern about students and faculty attempting suicide by leaping from University of Minnesota bridges. The Provost's Committee proposed to create and install a series of signs on the bridges that read, "There is Hope" with a 24/7 number to call to speak with a crisis counselor. Part of the work of the committee was to ensure that whenever calls came in from the campus, they would be answered by university-trained crisis counselors, because it will help individuals in crisis to talk with someone who understands the specifics of campus life at the university and the college experience.

Campus-Wide Mental Health Supports

The University of Minnesota has a wide range of departments and organizations dedicated to enhancing and promoting student mental health on campus. The university has three main entities that actively support and provide services for students with psychiatric disabilities: the DRC, the Boynton Mental Health Clinic, and Student Counseling Services (SCS). These three entities work closely together, and triage students among themselves depending on the presenting concerns and needs. Although these are three distinct programs each with a clearly defined mandate, there is a culture of shared responsibility among these programs to: (1) address the individual mental health needs of students: (2) to educate and promote a campus-wide culture of understanding about mental illness and mental health: and (3) and to reduce barriers for students with mental health disabilities.

  • Disability Resource Center: The DRC is housed within the Office of Equity and Diversity, and provides accommodations to students with various documented disabilities as mandated by the Rehabilitation Act of 1973 and the American with Disabilities Act (ADA) of 1990 and its subsequent revisions. In fiscal year (FY) 2014, the DRC served 2,125 students and 1,886 faculty, for a total of 4,011 individuals with disabilities and medical conditions. Mental health conditions are consistently the most prevalent of all disabilities seen in the DRC. In FY 2014, students registered with the DRC identified the following primary disabilities: mental health conditions (45%), attention deficit hyperactivity disorder (20%), medical and chronic health conditions (14%), learning disabilities (7%), brain/head injuries (3%), mobility/physical disabilities (3%), autism spectrum disorder (2%), blind/low vision (2%), deaf and hard of hearing (2%), and >1% unknown or with speech disabilities. For students with psychiatric disabilities, anxiety and depression are most prevalent.

    Students are most often referred to the DRC through faculty or advisors. Initially, a student meets with an access consultant to discuss his or her particular concern, any previous experience with receiving accommodations, and to review medical documentation and the student's course load. For students with mental health concerns, some of the most common accommodations include extra testing time, modified attendance requirements, and modified assignment dates. Imperative in the DRC mandate is that accommodations do not compromise the essential elements of the course. The ADA states that students seeking accommodations for classes must be otherwise qualified to take the class.

    A large part of the work of the DRC entails educating faculty and staff about what mental illness may look like, how it can present itself, and what resources and supports exist on campus. DRC staff provides in-person trainings to various departments and schools, and is currently creating an online training module that will be rolled out in the coming year. These DRC trainings are voluntary for University of Minnesota faculty and staff.

  • Boynton Mental Health Clinic: The Boynton Mental Health Clinic is housed within the larger Boynton Health Services, which is the primary health care provider on the University of Minnesota campus. The majority of students accessing the clinic self-refer, or are referred through the DRC or the International Student and Scholar Service (ISSS). Although all students using the clinic are assigned to individual therapists, group therapy and medication consultation are also available. Students have a limit of 11 individual sessions a year. While this is sufficient for most, staff will facilitate community referrals as needed if continuing care is indicated.

    Boynton Health Services conducts a bi-annual College Student Health Survey to provide a comprehensive look at the overall health of university students. Data from 2013 suggest that depression (19.3%) and anxiety (18.2%) were the two most frequently reported diagnoses. In addition, a total of 43.3% of students reported having 1-2 stressors within the past 12 months. The Boynton Mental Health Clinic uses these data to provide the most appropriate care to students and to determine how to focus services and supports.

  • Student Counseling Services: SCS offers counseling, academic support, trainings, and workshops to help students succeed academically. SCS staff work with students on a wide range of issues including mental health concerns, academic challenges, career uncertainties, and stress management. Referral and communication between the SCS and the Boynton Mental Health Clinic are fairly frequent. In addition, one SCS case manager is colocated at the DRC 1 day per week.

    In 2014, there were approximately 1,600 students that received individual counseling through the SCS. Nearly 80% of students receiving SCS services are classified as having some sort of mental health concern. The most commonly reported issues include depression, anxiety, and stress related to academia and personal life circumstances. There is a 15-session limit for all SCS services; when the session limit is reached, counselors will review the individual student's needs to determine if he or she qualifies for additional supports.

    SCS is launching a new pilot project with Boynton and ISSS called Feel Better Fast, which will offer a semester-long set of online mental health treatment modules addressing depression, stress, and anxiety. Students will have reading assignments and homework and will interact with a counselor providing feedback electronically. This project will be offered to all interested students and will have an integrated a research component to assess usability, satisfaction, and individual mental health outcomes.

Other University Partners in Promoting Student Mental Health

Part of what is unique about the University of Minnesota approach to promoting student mental health is the broad scope of departments and entities across campus invested in this initiative. The DRC, the Boynton Mental Health Clinic, and the SCS are obvious campus partners in addressing student mental health, but there are many other ancillary partners that actively participate in creating a culture to enhance and support student mental health. A few examples are detailed below.

  • International Student and Scholar Services: At the University of Minnesota, all international students (approximately 6,200 representing 142 countries) are required to be actively engaged with the ISSS. All international students must meet with ISSS staff regarding various issues specific to study in the United States (e.g., immigration forms, health care). ISSS stakeholders noted that many international students experience stress, depression, and anxiety. In response to the high prevalence of mental health concerns, ISSS leadership intentionally hired staff advisors with counseling backgrounds, a practice that is unique among offices of international affairs on other campuses. ISSS leadership considers mental health an important part of overall student health and well-being. Although advisors do not ask explicitly about mental health, they do look for signs of mental health need. ISSS staff uses a case management/social work approach, and focuses on whole student wellness.

    Learning Abroad Center (LAC): The LAC provides advising and support services to the approximately 3,300 students who study abroad each year. Although the LAC does not track how many of its students have mental health concerns, psychiatric disabilities and needs for accommodation make up the largest portion of its referrals from the DRC, at above 50%. LAC staff brings mental health into the conversation with students before they travel abroad. Among learning abroad programs on other campuses, the LAC is seen as a leader in addressing issues of student mental health, and LAC administrators are often asked to speak at conferences and in other college settings about their experiences. This attention to and awareness of mental health throughout the travel abroad process (both before and during oversees study) demonstrates the university's commitment to integrating mental health and wellness into all aspects of student life.

    Office of Student Affairs: The Office of Student Affairs has been key in setting the tone for embracing and promoting student mental health across the university. Student Affairs was involved with the Provost's Committee from its inception, and provides intermittent small grant funding to fund ongoing activities. The Office of Student Affairs reported that in interactions with other campus offices of student affairs, the most relevant issues to campus life were found to be mental health and sexual assault. As such, the leadership tends to shy away from funding cuts in these areas. As one stakeholder noted, "We want people to be successful and we recognize and address the whole person. We talk about mental health regularly, and help educate all our campus Deans."

Mental Health Promotion Groups and Events

There are countless groups and events throughout the year that promote and educate on student mental health. These include but are not limited to the following.

  • Cirque De-Stress: Cirque De-Stress is an annual event on campus where a Boynton Mental Health Clinic psychiatrist is the ringmaster and leads participants through a variety of stress reduction activities, including balancing a peacock feather on your hand or riding a unicycle. This event is very popular and provides a setting where students can enjoy a circus performance, actively participate in relieving their stress, and learn more about mental health and mental health resources on campus.

    Pet Away Worry and Stress (PAWS) Program: The Boynton Health Center sponsors the PAWS program. PAWS is a weekly event that features therapy dogs and rabbits, as well as a therapy chicken and a therapy miniature pony. Students can spend up to 2 hours with the animals as a way to relieve stress and anxiety. This program is very popular, and there are ongoing discussions to expand its presence on campus.

    Active Minds: The university has a robust chapter of Active Minds, the student-run national organization that focuses on raising awareness, promoting support, and eliminating stigma around mental health issues on campus. They host events on campus to educate the community on mental illness and mental health, participate in community service, and collaborate with other on-campus groups.

    Stressing Academic Success: Stressing Academic Success is a forum hosted by the Provost's Committee on Student Mental Health. The forum debuted in 2014 and brought over 200 faculty, staff, student, and university leaders together to have a conversation about stress on campus, the challenges faced by students, and strategies to address these concerns. Three active task forces emerged from the forum to move the work forward. Another forum will be held in October 2015.

Financing

Funding to support mental health accommodations and promotion activities varies across departments. What all departments stressed is that even with the vast prevalence of students with mental health concerns on campus and the recognized importance of providing mental health supports and resources, there have in essence been no new dollars (except the $10,000 in seed money) to support these activities. Departments have had to make choices about how to organize their staff and where to focus their resources within the financial packages they receive. Some noted that the high prevalence of students with mental health concerns may have prevented some departments from receiving funding cuts, but in general there were no new dollars to address mental health on campus.

Specifically, the DRC is centrally funded from the university. The Boynton Mental Health Clinic is funded through student service fees and third-party insurance payments. Funding for the SCS come through student tuition, as well as some funding from the state legislature dedicated to the university; the Office of Student Affairs determines how the legislature dollars are allocated. While public funding for universities in general has decreased over time, the SCS supports are considered critical services and have not received any funding cuts to date.

Successes and Challenges

There were many challenges and successes identified by program directors and stakeholders at the University of Minnesota.

Successes:

  • Campus culture regarding mental health is generally positive; there is little stigma associated with mental health issues.

  • The Provost's Committee on Student Mental Health has been able to engage the University Provost in decision-making and outreach efforts.

  • The large body of resources available on campus for both students and faculty--events, student counseling, mental health services, accommodations in classroom settings, trainings--makes it very easy for anyone to obtain mental health information or support services.

  • Trainings have been implemented to help staff and faculty better understand student mental health and mental illness, their role in responding to students in distress, disability accommodations, and resources available on campus.

Challenges:

  • Although there are a growing number of students who are in need of mental health services, the university has not been receiving additional funding.

  • The large student population of 48,000 on the Twin Cities campuses sometimes makes it difficult to outreach to all students, especially those who are at the graduate or professional school levels.

  • The campus has no policy that mandates trainings regarding mental health disabilities; there is variability in interest and follow through among staff and faculty to learn about all available mental health resources and accommodations.

  • Boynton Mental Health Center and the SCS have issues with effectively sharing files and documentation on medical records and student information.

Participant Stories

Two University of Minnesota students experiencing depression and anxiety participated in a single group interview. Participants described actively using the three main campus entities that support students with psychiatric disabilities: the DRC, the Boynton Mental Health Clinic, and the SCS. Specific accommodations included securing flexible classroom attendance, extensions on some assignments, a semiprivate classroom for testing, and facilitating extra time for exams. The SCS provided academic and study skills support, while the Boynton Mental Health Center provided therapy. Both students noted that their first step in finding mental health supports on campus was to check the university's student mental health web site.

Students felt that the university's resources met their health care and support needs. Students noted that their professors were very understanding about mental health accommodations. They did reflect, however, that some faculty could be skeptical about the need for accommodation, perhaps because psychiatric disabilities were less visible than other disabilities. Students noted that while there is perhaps less stigma on the University of Minnesota campus regarding mental health than other campuses, there are still many people who do not view mental illness as a disability. The students felt that there is still work to be done to raise awareness and destigmatize the topic.

5.3.5. Successes and Challenges across Sites

Each of the three sites were able to highlight specific successes and challenges in bringing SEd efforts to scale. These are summarized in Table 5-2.

TABLE 5-2. Summary of SEd Successes and Challenges across Sites
  EASA LEARN University of Minnesota
Successes State-level prioritization of EASA efforts Comprehensive and specified approach to SEd Creation of Provost's Committee on Student Mental Health
No waitlist for services Services are time-unlimited Large body of mental health resources across campus
Strong relationships between EASA participants and staff Strong working relationships between LEARN and area colleges Campus commitment to supporting student mental health
Educating participants and family members on supports to achieve educational goals Standardized data collection on education indicators that suggest positive outcomes Training for staff and students to understand mental health, disability accommodations, and available resources
Challenges Balancing "fit" of evidence-based approaches to immediate needs of EASA participants Providing rapid supports before challenges turn into crises Increase in demand for mental health services with no additional funding
Integration of SEd into IPS, resulting in concerns about IPS fidelity and decreased attention to educational goals Finding sources of funding for students to go to school Comprehensive outreach to a large student population
Lack of SEd specialists on most EASA teams Efficiently staffing multiple campuses with limited SEd personnel resources No mandates for faculty or staff to receive disability accommodation training
Limited standardized data collection on education outcomes Supporting students to integrate socially on campus Effectively sharing confidential student mental health information across campus departments

5.4. Case Study Cross-Site Integration

5.4.1. Similarities and Differences among the Three Settings

The three settings of the case studies are distinctly different. Nonetheless, we find notable similarities. Elucidation of these similarities provides guidance on how SEd may be construed and operationalized in the future.

Similarities across the Case Studies

  • The Importance of Academic Success: All sites shared a commitment to the educational success of students. All three sites indicated the criticality of academic achievement to the development of human and social capital. In terms of human capital, education was viewed as a lynchpin to later vocational success, and employment as the link to higher income that can reduce dependence on disability benefits. In terms of social capital, all three sites espoused that educational attainment is a critical step in human development. When this step is truncated by mental illness, there is a natural desire for completion, thus, for many, higher education was a central goal that should be honored. EASA considers education to be one part of a holistic approach to mental health recovery after illness. At the University of Minnesota, there is campus-wide recognition that poor student mental health will lead to poor outcomes as a student and later in life. As such, University of Minnesota leaders noted that mental health initiatives are "the last place we'll make cuts."

  • Initiation and Support "from the top down": At the start, all three sites essentially responded to a call from leadership to provide education supports. For LEARN, it was the state Department of Mental Health that initiated a contract to deliver these services. The EASA program responded similarly to a statewide initiative, and at the University of Minnesota it is the Provost's Committee on Student Mental Health that was instrumental in assuring a campus-wide approach to mental wellness. Although clearly there was interest and involvement from front-line and administrative staff in supporting educational goals, the impetus and ongoing backing of services and practices that meet these goals was defined by leadership. This suggests that future implementation of SEd would need similar upper-level backing. However, it is also notable that a "top-down" approach does not mean a regulatory approach, nor a federal initiative. In some sense, the SEd efforts were "home grown" on a local or state level.

  • A Functional Approach to Academic Success: Despite widely different settings, the focus of activities at all three sites was on how to help SEd participants or students successfully function in an academic environment. This focus is resonant with both occupational therapy and psychiatric rehabilitation approaches (i.e., teaching skills needed to meet the demands of an environment) and an intention to teach the skills so that individuals can later use these skills on their own. For students not yet enrolled in school there are important SEd activities pertaining to developing a clear educational goal, and choosing an academic or training program in keeping with that goal. Subsequent skills and activities pertain to obtaining educational enrollment and were highly important, especially for those SEd participants who were returning to college after prior failed attempts. These skills included: applying for a school or training program, completing FAFSA and other financial aid applications, clearing records of past student loan defaults or of college dropouts or failing grades, selecting a course load that is manageable, and registering for classes. Other skills concern strategies that promote student retention. These include organizational skills, time management and calendaring, study skills, note-taking, and use of campus resources. Importantly, all three sites focused on obtaining and using academic accommodations. Accommodations could include extended time for assignments, use of assistive technology in the classroom, adjustments to class attendance policies, preferred seating, isolated areas for test taking, and others. Sites would provide assistance and support in working with the student disability services office to develop an "accommodation letter," and to work with professors so that accommodations are applied. Providers and stakeholders in all three sites would help SEd participants or students manage requests for medical leaves and for returning to school after leaves.

  • Ameliorating Mental Health Distress that Impinges on Academic Functioning: In all three settings, academic skill development was complemented by attention to managing a mental health condition while pursing educational goals. Such efforts would be offering strategies for coping with or reducing stress or anxiety, assisting with depression or mental health crises, providing medication management as appropriate, accessing mental health counseling or treatment, teaching strategies for wellness, and assisting with socialization.

  • A Normalized, Flexible, and Individualized Approach: Services across the settings were uniformly community-based and integrated, making the three sites consistent with state-of-the-art approaches to mental health service delivery. That is, participants were enrolled in normalized community settings, real colleges and training programs open to anyone. Services were largely delivered in the community. LEARN coaches would meet SEd participants or students at their campuses. EASA staff would accompany SEd participants or students to community settings when needed, and University of Minnesota supports were fully integrated into natural campus settings. Another key feature of the strategies used is that they are tailored to the unique needs of the individual. Skills are taught and strategies are used that are in keeping with individual student needs and according to their choice and preference. This individualization lends itself to the flexible model of service delivery, "doing whatever it takes," espoused by EASA. Even the University of Minnesota, which has the most structured and defined set of strategies, will work with individual students to meet their unique needs as much as possible. Thus, much like SE, there is no one approach, or "one size fits all" model to deliver educational supports; creativity and flexibility of the provider are required.

  • Stable Funding and Longevity: Although the funding sources for educational supports differed, we noted that all three sites appeared confident that they would be able to continue to provide service and supports. All three sites had relatively long periods of sustained funding, suggesting that SEd has "staying power." This may be unique to these programs, and a function of and dependent on, the leadership support that first established these programs.

  • Participant Satisfaction: Participants at all three sites noted high degrees of satisfaction with the supports received. Participants consistently noted that providers were caring, patient, and knowledgeable. Students were able to identify specific skills they learned and critical activities of the SEd provider that promoted success. In addition, students valued the lack of stigma around mental health, and appreciated a focus on education and not simply one's mental health challenges. Some noted that their academic success was largely due to the help they received. We must acknowledge, however, that the participants in the site visits were selected by the sites themselves.

Differences between the Sites

  • Service Structure: We note that the structure of educational supports across the three sites were widely different: One serves a distinct population (first-episode psychosis), where education is one service embedded within an integrated system of care (EASA); one provides a public health approach including mental wellness in a large campus setting (University of Minnesota); and another is a standalone service delivered under the auspices of a community mental health agency (LEARN). Despite differences, we note that all three approaches were successful, suggesting that SEd models can differ and still be very strong.

  • The Culture of SEd Services: Each site embodies a unique service culture in which educational supports were delivered. While all three sites emphasized skill building, there were differences in how relationships with the provider were seen. EASA emphasized the role of the relationship between participants and EASA staff as critical to working with participants on skill development and to delivering education-focused services. At LEARN, the relationship was equally valued and important but seemed to develop as a result of skill building activities. There was less importance attached to singular relationships at the University of Minnesota site, where supports and skills were spread over three campus centers and embodied within the broader culture. Similarly, across the sites we observed a continuum of the degree to which the sites adhered to the "medical model." EASA can be considered as operating at one end of the medical model continuum, with an emphasis on recovery from psychiatric illness and recent hospitalizations. LEARN's approach is midway on the continuum--that is, operating out of a community mental health center but with a strong emphasis on community bridging. The University of Minnesota is on the opposite end of the continuum functioning entirely independently of the mental health system, and providing bridges back to the system as needed.

  • Models Used: We note that there was no one model for SEd available or used. Hence, each site developed approaches and services that best met the needs of their participants, resulting in differences across sites. Correspondingly, each site offered different opportunities. For example, by going through the mental health "door" (as in EASA), it may be easier to implement SEd especially when there is a SE component. On the other hand, the environmental approach used by the University of Minnesota may identify students who are in need of, but who have not yet accessed, mental health services. It is possible that this public health approach can work to prevent both student mental health crises and student academic failure.

  • Performance Measurement and Outcomes: The performance measures and evaluation strategies in the three sites differed. LEARN has the most rigorous outcomes data collection that focused on academic achievement, enrollments, credits earned, and degree completion. At EASA, academic outcomes are not systematically collected for all sites, but some of the pilot programs--specifically those working with VR--collected data on school starts and stops and enrollment status. At the University of Minnesota, there is no program per se to evaluate, and services are spread across various campus organizations, each with their own benchmarks and outcomes.

  • Relationship of SEd to SE: The degree to which education supports were integrated with SE varied by site. At EASA, there is very close integration of SEd to SE. Given the nature of the interdisciplinary team used in Oregon, this is not surprising. EASA commented that SEd often took a back seat to SE, particularly as fidelity to the IPS model of SE was tied to financial reimbursement for services. At LEARN however, SEd is a standalone service from SE with separate teams, trainings, and evaluation. Our visit at the University of Minnesota dealt primarily with their mental health campus culture and did not address how the University may be preparing students for employment.

Case Study Key Findings

We summarize the following key findings, taken together:

  • Educational goals of individuals with mental health conditions were supported across the lifespan.

  • Sites promoted educational success to improve employment prospects, personal development, mental health recovery, and acquiring social and human capital.

  • The practice of SEd of individuals with mental health conditions has common core elements pertaining to strategies for choosing, getting, and keeping an educational goal.

  • Widely different settings can successfully practice the core elements of providing educational supports.

  • The context in which SEd services are deployed will influence who is served and how they are served. Different settings will offer different opportunities and continued experimentation with how to deliver educational supports.

  • There was no consistency in evaluation attempts or methods across the sites.

  • Leadership endorsement and buy-in is needed to develop, implement, and sustain supports for educational attainment.

  • With leadership support, financing SEd programs appears more feasible.

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