External mental health service providers in schools and the effective delivery of school psychology services

Transcription

1 External mental health service providers in schools and the effective delivery of school psychology services APS Professional Practice November

2 The Australian Psychological Society acknowledges the work of the following members of the Psychologists in Schools Reference Group. Dr Monica Thielking Sue Sodeman Chelsea Eacott Lesley Fraser Darren Stops 0

3 TABLE OF CONTENTS 1. Introduction 1 2. A best practice model of school psychological service delivery 2 3. Service delivery models for school psychology Client-centred model Whole school service model Whole school service approach Indirect service approach Direct service approach 5 4. Privately operated Medicare-rebated psychological services 7 5. Choosing the best service delivery option Who owns psychological records? School employed psychologists Medicare funded, school located psychologists Private Medicare service providers What is the schools duty of care in the provision of psychology services? School employed psychologist service delivery Private Medicare service providers Disability Discrimination law obligations The need for a protocol between schools and mental health service providers who use Medicare services Conclusion 13 Appendix: Important considerations for schools when engaging with private providers

4 1. Introduction The Australian Psychological Society (APS) is the peak professional association for psychology and psychologists in Australia. A significant number of its members are school psychologists. This document provides guidelines for the delivery of effective school psychological services at a time when the economic and political climate is influencing all school sectors to explore the viability of outsourcing school psychological services to private providers in the community. This document has been written by the APS for school psychologists, their employers and policy makers within government, Catholic and independent schools in Australia. 2. A best practice model of school psychology service delivery The APS s preferred model of psychological service delivery in schools is for services to be provided by psychologists employed either by a local education authority, or directly by a school. There are clear benefits for a school in having a psychologist on staff as children and young people are more likely to seek help from a familiar and trusted school staff member than from an unfamiliar practitioner. Furthermore, a school-employed psychologist is accessible to both teachers and parents for advice regarding the emotional, behavioural or educational wellbeing of children. The continuity of support received from a school-employed psychologist allows students with ongoing mental health issues to receive continuing care and management as well as more regular or intense support if needed. Importantly, school psychologists can operate as the safety-net in schools for students who are vulnerable or in crisis, and children and adolescents will seek out the support of their school psychologist for a diverse range of issues. Research consistently indicates that teachers also highly value having the support of a school psychologist on staff and feel that their teaching is supported as a result of this effective relationship. School psychologists are well informed about current research in children and young people s mental health, learning, and teaching and are able to inform school policy, curriculum and decision making accordingly. The support, information and professional development they provide to the whole school community enriches the health and wellbeing of the community, as does their knowledge of and relationship with outside service providers. Psychologists who are employed by schools and who are embedded in the life and culture of a school are able to provide a broad range of services. 2

5 They can provide a developmental and psychosocial perspective on school policy, mental health literacy and student wellbeing. The APS acknowledges, however, that engaging external mental health providers may sometimes be an advantageous means of supplementing available psychological services in schools. Such an arrangement may provide an individual student who has more complex needs access to a psychologist with specialist expertise. This document describes the benefits that schools accrue when they employ school-based psychologists. It also describes the limitations inherent in the practice of schools engaging with external providers who use Medicare-rebated services. The model of service delivery preferred by the APS is the model where school psychologists are employed directly by schools or by a local education authority. 3

6 3. Service delivery models for school psychology A brief review of the development of school psychology services, the evolving models of service delivery and the current business climate in Australia which enables private providers of psychology service to work in schools will provide a context for describing the APS preferred model of service delivery. School psychologists work across all school sectors in a range of settings, including kindergarten, pre-school, primary, secondary and specialist schools. Currently, psychologists working in the government school system typically work across several schools in geographically located allied health teams. These teams have generally been co-located in a sector education office or in a designated host school that provides service for a specified local government area. School psychologists working in the independent and Catholic school sectors have more commonly been employed to work in one school. Service delivery models can be client-centred, whole school service models, or a mixture of both. 3.1 Client-centred model This is a traditional model of intervention in which psychologists work with one student with little intervention related to contextual factors. The important environmental influences of family, school and community are often not considered. This model has minimal impact on the organisational procedures and practices in the school setting and does not contribute to psychological prevention, intervention and post intervention practices which support whole school populations. 3.2 Whole-school service model Over recent years school psychology has evolved to a system-wide model of service delivery. School psychologists increasingly address the psychological needs of children and young people in the context of their school, home and community. The role of the psychologist has consequently expanded beyond a client-based focus to include systemic and preventative practices. As a result, therapeutic work focuses both on one-to-one sessions and indirect work, such as consultation and the development and implementation of prevention programs. When a psychologist engages with the context of the young person, the family and school become more involved in the intervention and outcome. This systemic model of service delivery ensures that more effective use is made of both the psychologist s skills and of available resources. 4

7 When school psychologists are employed as part of the school community they can offer three tiers of service delivery: Whole school service approach: Under this approach psychologists can design prevention work for all students. Examples of whole-school service approaches include provision of specialist input into the following: organisational procedures and practices in the school setting to provide psychological prevention, intervention and post intervention practices to support whole-school populations, for example: o assessment to assist teachers with planning relating to academic, behavioural, emotional, psychological and social problems o implementation of bullying, anti-violence and personal safety programs o implementation of whole school approaches to mental health and wellbeing such as Kidsmatter and MindMatters programs o referral to appropriate treatment programs o development of a whole-school approach to behaviour management and student psychological wellbeing o development of mental health intervention and illness prevention programs professional learning for teachers, parents and external agencies to address the psychological needs of students crisis management policy and relationships with emergency services and mental health agencies response and recovery strategies for school communities following a critical incident psychological input into teaching and learning practices in the school to assist learning across all groups, and teacher support and professional development training Indirect service approach: This is targeted intervention for groups or year levels of students who are at risk of disengaging from school for educational, psychological or social reasons. Examples of an indirect service approach include provision of specialist input into the following: consultation with teachers to provide information and advice about general mental health and other psychological issues affecting particular students consultation to determine programs, strategies and techniques for educational and psychological interventions parent information sessions about child and adolescent development and issues affecting mental health 5

8 consultation with parents about a child s difficulties and appropriate psychological interventions consultation with staff for individual and classroom management, learning and behaviour needs, and development, implementation and evaluation of individual and group interventions Direct service approach: this approach provides client-focused intervention for the most vulnerable children and young people in the school community. Examples of a direct service approach include provision of specialist input into: Assessment of a child or young person s cognitive, academic, social emotional and behavioural functioning problems including: o administration and interpretation of standardised tests of cognitive functioning, language functioning, visual and auditory perception, motor skills and social and emotional skills (for example: intellectual disability, specific learning disorders) o behaviour assessment (for example: autism, attention deficit disorder) o educational assessment, and o specialised mental health assessment and interventions (for example: anxiety and depression). Counselling and support of children and young people for cognitive, social emotional and behavioural problems including: o mental health problems o developmental issues o adaptive behaviour problems o problematic life events that can affect children and adolescents (for example: grief, loss, bullying, relationship difficulty, sexuality issues, identity issues, drug and alcohol issues, school to work transition, family breakdown, family violence, trauma), and o emotional regulation. 6

9 4. Privately operated Medicare-rebated psychological services The Australian education funding environment has traditionally provided principals and local education employment authorities (including school boards) with school or local area psychology resources. In 2006, the Australian Government introduced new Medicare items for psychological interventions by registered psychologists and certain other allied mental health professionals. As a consequence of this initiative, some private providers have begun to advertise services to schools under the Medicare Benefits Schedule. The providers often inform schools that services are free at the school to students who have been diagnosed with a mental disorder and have a Mental Health Care Plan from their General Practitioner (GP). There are a number of conditions that have to be met, however, before a student can access the services of a Medicareendorsed psychologist and the following points outline these and other important considerations for schools when engaging with private providers. 4.1 Currently under the Medicare scheme, all psychologists, and other allied mental health professionals who are endorsed by Medicare to provide mental health services, can provide an individual with up to ten sessions per year of Medicare-rebated treatment for diagnosed mental health disorders. The individual (including children and young people in school) must return to the GP for a review after six sessions. 4.2 Under these arrangements, the term mental health disorder is used to describe a range of clinically diagnosable disorders that may significantly interfere with a person s thoughts, emotions, social or decision-making abilities. These comprise: psychotic disorders schizophrenia bipolar disorder phobic disorders anxiety disorders adjustment disorders depression sexual disorders conduct disorders bereavement disorders post-traumatic stress disorder eating disorders panic disorders 7

10 alcohol use disorders drug use disorders sleep problems attention deficit disorder obsessive compulsive disorder co-occurring anxiety and depression. These are the only issues that can be treated under Medicare. 4.3 It is important to note that school-specific issues such as the assessment of learning difficulty or intellectual disability, or the delivery of psychological strategies for managing relationships or study issues, while arguably the most common presenting issues in schools, are not mental disorders eligible for Medicare-funded service. These are school-specific issues affecting children and young people and they are able to be addressed by school psychologists. They are not able to be addressed by psychologists in the community under Medicare. 4.4 For a student to be able to access the services of a psychologist under Medicare, a GP, psychiatrist or paediatrician must first assess the need for such a service. If the medical practitioner (most often a GP) assesses the patient as having a mental health disorder, they may refer him or her to a Medicareendorsed provider of their or the patient s choice for up to ten sessions of approved psychological treatments per year. The student must be reviewed by their medical practitioner after six sessions to determine if additional sessions are necessary. 4.5 The Medicare-approved treatments are: Psycho-education (including motivational interviewing) Cognitive-behavioural therapy, including: o Behavioural interventions o Behaviour modification o Exposure techniques o Activity scheduling o Cognitive interventions o Cognitive therapy Relaxation strategies o Progressive muscle relaxation o Controlled breathing Skills training o Problem solving skills and training o Anger management o Social skills training 8

11 o Communication training o Stress management Parent training Interpersonal therapy (especially for depression) Narrative therapy (for Aboriginal and Torres Strait Islander people). 4.6 At a time when budgetary decisions, particularly in the government sector, are increasingly being devolved to schools or local networks of schools, school psychology provision through Medicare funding has created the potential for the delivery of more psychology services to students. The scheme is not, however, designed to work as a stand-alone service delivery option for schools. 4.7 Under Medicare-funded service delivery, a diagnosis of a mental health disorder must only be made where there is clear evidence of its existence. Transient conditions and those associated with certain developmental periods or life stressors (for example, appropriate grief or bereavement or exam anxiety) are not mental health disorders. There is a range of potential long-term consequences of a mental health diagnosis for a student about which schools and psychologists need to be mindful. A young person s diagnosis of a mental health disorder, may, for example, limit career opportunities in the defence force, or have future medico-legal implications. Consequently, it is important that appropriate caution be exercised when diagnosing children and adolescents. 4.8 The use of Medicare-funded service delivery has clear implications for the continuity of care for students who may be in need of ongoing support. In addition to the services being time-limited, psychological records may not be able to accompany a student between schools. Private providers may also not be available to collaborate extensively with school staff around meeting student needs. For more detailed information on the Australian government initiatives that enable people to access psychological services under Medicare for mental health disorders, go to: 9

12 5. Choosing the best service delivery option for your school In considering outsourcing options for school psychology service delivery, schools are advised to consider the following questions and operational issues: 5.1 Who owns student psychological records? School employed psychologist: When psychologists are employed directly by a school or by a local education authority, confidential records are the property of the school or education authority and remain at the school when the psychologist has finished working with the student Medicare-funded, school-located psychologist: If a school elects to contractually employ and locate a psychologist under a Medicare arrangement within the school, it will also be the case that the confidential records are the property of the school, provided it is specifically incorporated within the psychologist s employment contract. Under both of the above scenarios, records, learning plans and assessments can be accessed by another psychologist where a future need arises and teachers can thus be made aware of the student s learning needs Private Medicare service providers: Medicare-funded psychologists are independent practitioners and all student records and assessments are the property of the psychologist and cannot be passed on to the school without client permission. These files cannot remain at the school after the psychologist has completed their work with the child or young person nor can the files accompany the child or young person between schools. 5.2 What is the school s duty of care in the provision of psychology services? School-employed or education authority-employed psychologist: Under all service arrangements there is a legal duty for schools to maintain the safety and well-being of pupils in their care. This duty of care also arises where a psychologist-student relationship exists. Psychologists and school authorities owe a duty of care to take reasonable steps to ensure that their acts or omissions do not cause reasonably foreseeable injury to children or young people and to consider all legal requirements associated with working with children Private Medicare service providers: When principals and local employment authorities are considering engaging a privately-operating Medicare psychologist there are important considerations that need to be taken into account because 10

13 the psychologist will operate as a private practitioner rather than a member of staff. Schools are advised to consider what state or territory legal requirements need to be met in this situation and what visitor policies need to be in place to authorize access to school grounds and students. As a private therapist is not a school employee, and is not under the direction and control of the principal, there can be significant issues in relation to the discharge of the school s duty of care to students. The special duty of care held by teachers to take steps to prevent reasonably foreseeable harm to students cannot be discharged when an external provider is supervising or working with a student alone in a room that is not in the line of sight of a teacher. Hence, schools may not be able to meet their duty of care obligations to children or young people who are provided with private therapy in a withdrawal setting during school hours. It is also the responsibility of the principal to ensure that all people who engage in paid or voluntary child-related work in a school hold a working with children check (or related screening obligation) and a criminal record check Commonwealth Disability Discrimination Law obligations: To discharge their legal obligations under Disability Discrimination legislation schools are required to make reasonable adjustments to curriculum and to the physical environment for a student with a disability. The law covers all students with a disability and includes physical, intellectual, medical and mental impairments. In school settings it is important that there is regular communication between psychologists, school staff, families and community agencies about any adjustments that need to be made to curriculum or the environment to maximize a particular student s learning opportunities. This could take the form of discussions, reports, intervention plans or case conferences. However difficulties can arise when an external provider is providing service to a student with a GP Mental Health Care Plan. An external provider is not able to claim a Medicare rebate for any time given to writing reports, case conferences or making recommendations to school staff regarding adjustments that might need to be made to meet the young person s learning needs. 11

14 6. The need for a protocol between schools and mental health service providers who use Medicare-funded services If a school engages private providers of psychological services under Medicare, there are important issues to consider in order that the school can adequately deal with its legal and ethical obligations. The school should establish a protocol describing the conditions under which the services of a privately operated Medicare-rebated service provider will be engaged. This protocol needs to augment or stand alongside any existing school psychology services policy and any legal obligations. At a minimum, such a protocol should cover factors such as: the mechanism for identifying children and young people with mental health disorders how referrals to the external provider will be made and monitored how (and by whom) referrals will be obtained the administration and funding of GP visits for referrals informed consent for a child or young person to be referred to a GP liaison with the GP regarding the Mental Health Care Plan scheduling appointments with the psychologist the location of the psychology service within the school and hours of service availability the nominated school contact person for a privately-operated Medicarerebated psychological service provider the way in which a child or young person s rights to privacy, informed consent and confidentiality will be protected the specific business relationship between the school and the private provider the way in which requests for information regarding attendance and progress in treatment will be made available to the child s parents, carers or guardians the applicable mandatory reporting requirements, for example, dealing with disclosures relating to suicidal tendencies, sexual assault or bullying so that the school can take appropriate action to implement all relevant welfare supports, and, if appropriate, discharge its mandatory reporting obligations (if not detailed in the existing school psychology services policy) the school s expectations of the private provider pertaining to duty of care, confidentiality and record storage, access and retrieval and security protocols the school s expectations for a complaints process and the way this will be advertised the management of business issues such as public liability insurance, professional indemnity insurance, criminal record checks and working with children checks, and the supervision arrangements for the practitioner. 12

15 7. Conclusion There are important considerations for schools when engaging with external mental health care providers. In making any decision about the provision of psychology services in schools, it is important for school leadership or administrative personnel to understand what services can be provided, the conditions under which they may be provided and the limitations which apply. This is the case irrespective of how psychology services are delivered. The following appendix explores these important considerations more fully. It describes the organisational and logistic questions that need to be addressed in a service provision protocol between schools and external mental health care providers. For more information, please contact the Australian Psychological Society on , or visit the website:

16 Appendix Important considerations for schools when engaging with external mental health care providers There are a number of legal, ethical and practical issues that must be taken into consideration when any psychologist is engaged to work at a school. When the psychologist is a mental health service provider external to the school and is contracted to see children or young people under the Medicare system, the issues for the school can become more complex. Issues pertaining to the school s duty of care to the student can cause the most difficulty. Expectations and legal requirements around the following questions need to be clarified: Referrals What services will be provided to those children and young people who don t have a diagnosed mental health condition (that is students with other serious issues for example, students with learning disabilities.)? What services will be provided to students who do not wish to have a permanent record of having a mental health disorder on their medical and school file when they are referred under a GP Mental Health Care Plan? How will children and young people be identified as possibly benefiting from such a service? How will referrals be made and how will parents be informed or included in the decision making? Who will pay for the appointments with the GP? Who will be the main contact person within the school to liaise with the psychologist or the GP? Will the principal (or other staff member) be expected to manage the referral to the medical practitioner? Informed consent Will parent permission, or the permission of a young person, be required before a young person is referred to a medical practitioner for a psychologist referral? How will students be fully informed about the details of the service and about their right to choose whether or not they attend the psychological service? Will students be informed about the limits to confidentiality? 14

17 How will students be informed of the possible (and extent of) communications between the private provider of psychological services and the school psychologist (or other school referrer)? Service provision How responsive are external service providers? Will they attend schools for urgent issues? Will external providers attend the school if there are only a small number of appointments scheduled on a given day? How will student appointments be made and what procedures will be in place to ensure that students are informed discreetly about their appointments with the private psychologist? How will students be called to appointments and how will class teachers be informed of this? Provider-school relationships What legal responsibilities fall upon the school for the health and wellbeing of the private provider working on its property? What compliance requirements need to be met by the private provider and how will these be monitored? For example: o compulsory training in responding to child abuse and neglect o completion of National Child Safety Policy statement o evidence of professional indemnity insurance o Working With Children or child related employment screening obligations and o criminal record checks What legal responsibilities fall upon the school for the actions and competence of the private provider? How much information (if any), will be passed on to the school about the nature of the student s problems, and how will this be negotiated while ensuring confidentiality and privacy? Will the school be informed about significant student issues such as sexual abuse, drug-use or pregnancy? How will this be negotiated within the law? How will the school be informed about how best to support and educate a student who has mental health difficulties? How will this occur, how will confidentiality be maintained, and what understandings will the student and family have? 15

18 Can the school and its staff expect to receive training and information about children and young people s issues from the private provider? If so, at what cost, and what will be the legal responsibility of school staff to implement interventions based on the private psychologist s information? How will the services provided by the employed school psychologist be integrated with the private psychological service to fully meet the needs of children, young people and staff and how will their roles, caseloads, and other duties be managed? Information and records Where will the private psychologist s records be stored and how can the school be assured that the confidential files, containing sensitive information about the student and/or the school, are kept in a secure location? How long will the records be kept and what are the conditions around file ownership, and possible student access to the files? Where will the school records of referrals and other confidential information be secured within the school, and who will have access to these documents? Given that under some arrangements the records do not belong to the school, how will this affect the school s responsibility to address issues that may arise at the time or subsequently? 16