The Other 60 Percent

Medicaid money a boon for wellness in schools

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

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

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

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

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

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

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

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

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

Expanding and sustaining health efforts

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

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

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

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

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

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

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

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

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

Who’s in and who’s out

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

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

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

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

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

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

New rules beneficial

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

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

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

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

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

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

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

chronically absent

One in four students are chronically absent in Tennessee’s state-run district. Here’s what educators are doing about it.

PHOTO: (Lance Murphey, Memphis Daily News File Photo)
About 25 percent of students at Humes Preparatory Academy Middle School were chronically absent last year, a drop of 6 percent from 2017.

More than one in four children in Tennessee’s state-run turnaround district were chronically absent from school last year. Until recently, Armani Fleming, an eighth-grader in Memphis, risked being among them.

Armani struggled with attendance until a student support specialist with Communities in Schools, a Memphis nonprofit focused on wrap-around services for children, worked with him to identify and resolve barriers keeping him from class at Humes Middle School, apart of the Frayser Community Schools charter network.

“I realized Mr. B really cared about me, and he’s helped me make sure I come,” Armani said of the support specialist, Cadarius Buckingham. “He’s more of a counselor to me. I come and talk to him about everything, he’s the person I come to when I need help … and me coming to school has gotten a lot better.”

In the Achievement School District, getting kids to show up at school matters. Recent research has shown that when students have more “familiar faces” around them in class, they’re less likely to be chronically absent. Which is why nonprofits like Communities in Schools are sending staff members into local schools to connect with students like Armani.

Tennessee created the Achievement School District in 2012 to fix its lowest-performing schools by turning them over to charter organizations, but it has struggled to move the needle. Last year, 27.4 percent of the district’s students were chronically absent — representing a 2.4 percent drop from the previous year, but still alarmingly high. Now composed of 30 schools, the district faces higher rates of student mobility and poverty, contributing to its challenges with absenteeism.

Statewide, more than 13 percent of students are chronically absent, defined as having missed 10 percent of the school year, which is typically 18 or more days, for any reason (including excused absences and suspensions), but the average rate was significantly higher, 21 percent, for students who live in poverty.

The stakes are high for improving attendance numbers. Chronic absenteeism is now a major part of Tennessee schools are held accountable by the federal government. And research shows that children who are chronically absent from school are often academically below grade-level, more likely to drop out of school, and more frequently involved in the criminal justice system.

Communities in Schools is now in 19 Memphis schools, eight of them state-run. Those schools have seen, on average, a 5 percent reduction in chronic absenteeism, according to Michael Russom, the group’s director of operations and communications.

One school, Cornerstone Prep Denver Elementary, saw even more dramatic results: an 18 percent drop in chronic absenteeism year-over-year. Last year, just 13.7 percent of the school’s students were chronically absent.

What made the difference? Capstone Education Group, the charter school operator that runs Cornerstone schools, has a staff member dedicated to improving attendance and a partnership with Communities in Schools, said Drew Sippel, executive director of Capstone, which runs two state-run schools in addition to Denver that also had low absenteeism numbers.

“Whenever a parent expresses some concern related to regular attendance, [Patricia] Burns works to resolve impediments to consistent attendance,” Sippel said of the school’s Manager of Student Information and Business Systems. “These impediments range from transportation, homelessness, and inability to purchase school uniforms.”

Untreated health issues is sometimes another factor.

Denver Elementary’s principal also worked with Capstone staff to increase the number of meetings with parents, and therefore, to pinpoint the root causes of students’ absences.

Agape, Whitney Elementary, Memphis
PHOTO: Caroline Bauman
Two of Agape’s staff members work with students on reading at Whitney Achievement Elementary School. The staff members, though employed by the Memphis nonprofit, are integrated into school life.

“There’s often an assumption or judgment with parents, ‘Why don’t you just make your kids go to school?’” said David Jordan, CEO of Agape, a Christian nonprofit that has also seen success in reducing chronic absences in Memphis schools. “We keep data on this, and it’s not that parents don’t care. There’s a lot of issues that can prevent students from making it to class.”

The program has grown every year from when it began in 2013 with 113 students. Now, more than 550 students are a part of Agape programs in 16 schools throughout Memphis — and all students they work with are now at school for at least 85 percent of the school year. This is just shy of the group’s goal for Agape students: to attend more than 90 percent of the year.

For its part, Communities in Schools hopes to expand onto additional Memphis campuses, but for now, the focus is the schools they are already serving. And they have added additional staff to some of the highest-needs schools.

One such school is Fairley High School, an Achievement District school run by the charter operator Green Dot Public Schools. There, about 56 percent of students were chronically absent last year, a 19 percent increase from 2017. Russom said they placed two full-time support specialists within Fairley earlier this school year.

Last year, absences spiked at Fairley amid a change of leadership at the school, and it took time for the new principal to gain students’ trust, said Zachary Samson, Green Dot’s area superintendent.

“That’s one huge piece of chronic absenteeism that’s hard to quantify,” Samson said. “It makes such a difference when a student walks in the door, and I as a school leader am able to greet them by name. I know their mom. It’s students feeling seen and appreciated.”

To improve attendance, Samson said his staff is working with Communities in Schools to create an incentive program for students, in which students who meet their attendance goals can attend school parties. He added that they are also focusing on their communication with parents, as many parents may not be aware their children are chronically absent or of the consequences.

Samson said he’s confident attendance can improve at Fairley because he’s seen it happen at another Green Dot school – Wooddale Middle School. About 15 percent of students were chronically absent at Wooddale last year, a drop of 3 percent from the previous school year.

Communities in Schools has a full-time staff member at Wooddale, and that has made an enormous difference, Samson said, noting: “For schools where budgets are very, very tight, having another passionate educator in your school whose big focus is to address attendance and behavior with students – that’s a huge help.”

Update: This story has been updated to clarify that the state defines chronic absenteeism as missing 10 percent of attended school days, which is typically 18 or more days for the school year.

Correction: This story has been corrected to say that one in four students in the Achievement School District were chronically absent last school year, not one in three.

behind the budget

Surprise: Most funding for New York City’s ‘community schools’ going to academics, not social services

PHOTO: Alex Zimmerman/Chalkbeat
Principal Asya Johnson of Longwood Preparatory Academy, a community school, corrals a student between classes.

When Mayor Bill de Blasio promised a new “community schools” program during his 2013 campaign, it was in part a repudiation of his predecessor’s focus on improving academic results.

Rather than punishing schools when students struggle, the theory went, the city should flood schools with services to combat the problems that hold students back from succeeding. The city has included schools with a range of academic performance levels in the program, and officials have said their main goal is to increase equity, not test scores.

So it’s surprising that just a small fraction of this year’s extra spending at the city’s 239 official community schools is going toward physical and mental health services, while about 60 percent of the $198.6 million being spent on the program is going to academic services.

That’s according to a new analysis by the city’s Independent Budget Office, which looked at school-level spending plans produced for the first time this year under a new state transparency law.

The city education department is disputing the budget office’s methodology but not the conclusion that community schools are spending heavily on academic services. Community schools choose which programs and services to offer, based on their students’ needs; the academic services category includes spending on anything beyond traditional classroom instruction, including gifted programs, extra tutoring, and services for students with disabilities.

The spending analysis offers important context for an external evaluation of New York City’s program by the Rand Corporation, which is expected in 2019. It could potentially add to an existing body of research suggesting that efforts to combat poverty by providing “wraparound services” in schools often — though not always — generate improved test scores. The research has so far not answered the question of what makes some programs more successful than others, so knowing that New York City’s results come after spending heavily on academic services will add an important data point.

Early in the program’s development, some advocates pressed the city to tackle academics in addition to social challenges. But how much the community schools model is boosting academic improvement remains an open question locally, and the spending analysis offers important context for an external evaluation of New York City’s program that is expected in 2019.

Education department spokesman Doug Cohen said the state’s fiscal reporting requirements don’t reflect the city’s “holistic” approach to supporting schools. He said the discrete spending categories obscure the reality inside schools, where various programs interact in complex ways.

After-school programs, for example, might offer emotional support for students, Cohen said, adding that the overlap is an important feature of the community schools model.

“If we were only doing mental health alone,” he said, “it wouldn’t really be a community schools strategy.”