A Guide to K-12 Student Behavioral Health Supports with a Focus on Prevention, Early Intervention, and Intervention for Students’ Social, Emotional, and Behavioral Health Needs

(1) The general assembly finds that:

• (a) School mental health professionals, including school social workers, positively impact the school environment by working with young students and their families to identify safety-net insecurities, social and emotional skills deficits, instances of abuse and neglect, and mental health challenges;

• (b) Identifying these student issues as early as possible increases the likelihood that problems can be resolved successfully and in a manner that decreases long-term problems with learning and other barriers to student success in the future;

• (c) A pilot program that places a team of school mental health professionals in every pilot program school will allow the team, in partnership with classroom teachers, to provide needed support for young students and their families at a critical time in their education;

• (d) A significant goal of the pilot program is to ensure that students of elementary age receive the right level of necessary services, in the right place, and at the right time;

• (e) Receiving the right level of services, in the right place, and at the right time helps remove the burden placed on teachers to be everything to a student, from therapist to family counselor, and instead allows teachers to return to their primary task: Teaching; and

• (f) The pilot program will enable parents, students, teachers, administrators, and school mental health professionals to create a safe, positive, and successful school learning environment.

(2) Therefore, the general assembly declares that the creation and successful implementation of a Colorado K-5 social and emotional health pilot program could have a profound impact on the early educational and social experiences of kindergarten through fifth-grade students, resulting in those students graduating to middle and high school programs with fewer social, emotional, and behavioral issues; adverse childhood experiences; disciplinary referrals and delinquent conduct; school absences and truancy; and incidences of self-harm.

(1) There is created the K-5 social and emotional health pilot program in the department to determine the impact of dedicated school mental health professionals in kindergarten through fifth grade in elementary schools that have high-poverty, high-need students. The pilot program is implemented within the selected pilot schools and administered by the department as a pilot program for three consecutive school years, unless extended by the general assembly. Subject to available appropriations or gifts, grants, or donations for the three-year term of the pilot program, pursuant to section 22-102-106, the department shall employ or contract with a pilot program coordinator and contract for preliminary and final program evaluations of the pilot program. The department shall promulgate any rules necessary for the administration of the pilot program.

(2) (a) Subject to available appropriations or gifts, grants, or donations for the three-year term of the pilot program, no later than January 15 immediately preceding the first implementation year, the department shall select up to ten pilot schools to participate in the pilot program. If available appropriations and gifts, grants, or donations are insufficient to fully fund the pilot program, the department may select fewer than ten pilot schools to participate in the pilot program. The department shall select pilot schools that exhibit the characteristics set forth in subsection (2)(b) of this section and that are appropriate test schools to evaluate the impact and effectiveness of the pilot program. The pilot schools must demonstrate a willingness to participate in the pilot program and to collect the data and information necessary for the evaluation of the pilot program.

• (b) The department shall select pilot schools, including rural, small, and geographically diverse schools, which schools shall be located in a school district that has a high rate of youth suicide, attempted suicide, or suicidal ideation; have a high-poverty student population and a high percentage of students who experience or may experience food insecurity, as evidenced by the number or percentage of students in the school who are eligible for free and reduced-priced meals; and may include schools:

• (I) In large, metropolitan school districts;

• (II) That have significant ethnic, cultural, and language diversity within their student populations, which may include students from refugee populations;

• (III) That have a high number or density of youth who are students in out-of-home placement, as defined in section 22-32-138;

• (IV) That are in a school district that has a high percentage of students who are adjudicated delinquent; and

• (V) That are in a school district that has a plan in place to recruit, hire, and retain a diverse workforce that reflects the race, ethnicity, and other characteristics of the student body.

(c) Prior to a selected school implementing the pilot program pursuant to this article 102, the school must notify all parents or legal guardians of students at the school of the school's selection as a pilot school.

(1) In the first and subsequent years of operation of the pilot program, each pilot school shall employ or contract with additional school mental health professionals so that each of grades one through five and the kindergarten program in each pilot school has a school mental health professional dedicated to each grade and the kindergarten program. If a single grade or the kindergarten program has more than two hundred fifty students, additional school mental health professionals must be added to the grade or kindergarten program to maintain a ratio of approximately one school mental health professional per two hundred fifty students, as determined by the pilot school. A small pilot school shall maintain a ratio of approximately one school mental health professional per two hundred fifty students, as determined by the pilot school. At least one of the school mental health professionals at each pilot school must be a school social worker.

(2) The goal of the pilot program is for a school mental health professional to develop an ongoing relationship with pilot school students and to follow those students, to the extent possible, as the students advance through the grades at the pilot school. This will allow the school mental health professional to understand the needs of the students and their families over time and to help address those needs over time, if necessary. To achieve this goal, school mental health professionals may be assigned to a cohort of students by grade or, in a smaller school, by multiple grades. School mental health professionals in each pilot school shall work as a team to address the academic and social-emotional needs of the pilot school's students and to create a safe and positive school learning environment through additional behavioral health supports.

(3) For purposes of implementing this pilot program, the general assembly shall appropriate to the department for distribution to the pilot schools, or to the governing body for the pilot school, the amount of money necessary for the pilot schools to employ or contract with the number of additional school mental health professionals necessary to implement the pilot program, as described in subsection (1) of this section. Throughout the duration of the pilot program, the pilot school must employ or contract with, at the pilot school's expense, the same number of school mental health professionals employed by or contracted with the pilot school during the 2019-20 school year, so that the appropriation to the pilot school for the pilot program supplements, but does not supplant, the pilot school's existing expenditures for school mental health professional positions prior to the operation of the pilot program.

(4) (a) In implementing the pilot program, the school mental health professionals shall work as a team, with each professional providing services to students and offering training and resources to school faculty and administrators that are authorized under the school mental health professional's special services license and endorsement.

• (b) In addition, school mental health professionals shall, consistent with the school mental health professional's job duties and licensure:

• (I) Provide the school with resources to develop and improve the social and emotional health of students, including resources translated into the primary languages of the student population to the extent possible, and create a safe and positive learning environment through additional behavioral health supports; and

• (II) Provide social and emotional skill building in the school and with students in the classroom.

• (c) School mental health professionals may, consistent with the school mental health professional's job duties and licensure:

• (I) Assist students and their families with applying for and obtaining necessary public benefits for which each student and the student's family is eligible;

• (II) Provide services and supports to students who have an individualized education program, as provided in section 22-20-108;

• (III) Consult and coordinate with other school professionals on behalf of students and support families accessing community-based resources as needed and appropriate; and

• (IV) Identify food insecurity, homelessness, and other issues affecting students and make referrals to services within the community, bringing those services into the school setting where possible.

• (d) As appropriate, and to the extent possible, the school mental health professional must provide services or arrange for services to be provided for students at the school and during school hours or when student busing is available.

• (e) Services provided by the school mental health professional to the student must include the student's family and household, where appropriate. The school mental health professional is specifically authorized to make home visits when appropriate under the circumstances and consistent with licensure.

(5) Each pilot school's team of school mental health professionals shall participate in the school's or school district's multi-tiered systems of support process to assist in developing appropriate plans for the mental health and behavioral needs of individual students.

(6) Each pilot school, or each pilot school's governing body, where appropriate, shall collect, transmit, and retain any data and information necessary for the evaluation of the pilot program pursuant to section 22-102-106. Each pilot school shall record the unique student identifier, as defined in section 22-16-103, for all students enrolled in the pilot school.

(7) A student who is home-schooled but who participates in extracurricular activities or athletic programs at a school that is selected as a pilot school is excluded from any data collection or reporting requirements pursuant to this article 102.

(1) The department shall employ or contract with a pilot program coordinator to oversee the implementation of the pilot program across the pilot schools. The pilot program coordinator must be a school social worker who shall work with each pilot school's team of school mental health professionals. The duties of the pilot program coordinator include, at a minimum:

• (a) Coordinating data collection and program evaluation requirements with the professional program evaluator retained pursuant to subsection (2) of this section;

• (b) Serving as a contact person and resource for teams of school mental health professionals in the pilot schools;

• (c) Helping pilot schools identify successful practices for recruiting and retaining mental health professionals;

• (d) Sharing best practices relating to the pilot program and its implementation at the pilot schools; and

• (e) Ensuring fidelity to the goals of the pilot program across the pilot schools.

(2) (a) The department shall select a professional program evaluator to complete a preliminary evaluation of the pilot program on or before September 1, 2022, and a final evaluation of the pilot program to be completed on or before September 1, 2023. The department shall contract with the evaluator prior to the implementation of the pilot program in the pilot schools during the 2020-21 school year to create a process for the collection and transmission of data and information to the evaluator to ensure that the evaluator has the data and information necessary to complete the preliminary and final reports concerning the impact and outcomes of the pilot program. The pilot program evaluator, in conjunction with the department, shall select a group of control schools that have school characteristics and student demographics similar to those of the pilot schools, to serve as a control group for purposes of evaluating the impacts and outcomes of the pilot program on participating students and pilot schools. Data collected for pilot schools and control group schools must include data from school climate and healthy schools surveys for any grade in which such surveys have been created.

• (b) The department shall select a professional program evaluator that has the knowledge and skills necessary to evaluate the effectiveness of services provided by the pilot program and the resulting impacts and outcomes of the pilot program on the student cohorts participating in the pilot program. The department is encouraged, but is not required, to contract with a state institution of higher education to complete the evaluation of the pilot program.

• (c) The department and the pilot schools shall cooperate fully with the pilot program evaluator's collection and analysis of data and information relating to the pilot program's impact and outcomes. The department, pilot schools, the pilot program coordinator, and the contracted evaluator shall comply with all state and federal laws relating to the confidentiality of academic and medical records of students and shall provide aggregated data where appropriate.

• (d) The pilot program evaluator shall determine the impact of the pilot program on students' academic, mental, social-emotional, and physical health and well-being. The evaluator shall collect and analyze data relating to student and school outcomes, which outcomes may include:

• (I) The increase or decrease in students' disciplinary referrals, either within the pilot school, or pilot school's district, if relevant, or with law enforcement, and the increase or decrease in students adjudicated delinquent within the pilot school's district;

• (II) The increase or decrease in students' lost instruction time due to disciplinary action or visits to the school nurse or school counselor;

• (III) The increase or decrease in excused and unexcused absences and truancy;

• (IV) The increase or decrease in overall student performance on statewide assessments, by grade;

• (V) The increase or decrease in the student cohorts' grade point average, by grade;

• (VI) The increase in access to supportive services for students and their families, as evidenced by: (A) An increase in the number or percentage of students identified as eligible for free or reduced-price meals, by grade; (B) An increase in employment outcomes for students' families; (C) An increase or decrease in students' food security as demonstrated by an increase or decrease in the number or percentage of students participating in the federal supplemental nutrition assistance program; (D) An increase or decrease in the number or percentage of eligible students accessing public benefits; (E) An increase or decrease in the pilot schools' awareness of or involvement with domestic violence or child abuse issues affecting students; (F) Impact on the school's learning environment and changes to the school climate during the operation of the pilot program and evaluation of school climate; (G) The reduction in adverse childhood experiences or the positive resolution of adverse childhood experiences, if available; (H) The reduction in youth suicide and attempted suicide; and (VII) Any other relevant data and information relating to pilot program outcomes and impacts as determined by the pilot program evaluator.

(5.5) "Local student wellness program" means a program adopted by a school district, board of cooperative services, or facility school that is coordinated with health education and is designed to provide services to students in one or more of the following areas:

• (a) Physical education;

• (b) Nutrition services;

• (c) Mental health counseling and services;

• (d) Promotion of a healthy school environment;

• (e) Health education;

• (f) Health services;

• (g) Involvement of students' families and communities in supporting and reinforcing healthy choices.

(5.7) "Positive youth development" means an approach that emphasizes the many positive attributes of young people and focuses on developing inherent strengths and assets to promote health. Positive youth development is culturally sensitive, inclusive of all youth, collaborative, and strength-based.

(1) There is hereby created the Colorado comprehensive health education program, which shall be a voluntary program in which school districts, boards of cooperative services, and facility schools may participate through the creation of local comprehensive health education programs, which may include coordination with local student wellness programs. Implementation of the Colorado comprehensive health education program shall be a cooperative effort among the department of education, the Colorado commission on higher education, the department of public health and environment and other health education professionals, and participating school districts and boards of cooperative services.

(2) The department of education shall have the authority to promote the development and implementation of local comprehensive health education programs and local student wellness programs.

(1) Each school district, regardless of the number of students expelled by the district, may enter into agreements with appropriate local governmental agencies and, to the extent necessary, with the managing state agencies, including the department of human services and the department of public health and environment; with community-based nonprofit and faith-based organizations; with nonpublic, nonparochial schools; with the department of military and veterans affairs; and with public and private institutions of higher education to work with the student's parent or guardian to provide services to any student, or the student's family, who is identified as being at risk of suspension or expulsion or who has been suspended or expelled. Any services provided pursuant to an agreement with a nonpublic, nonparochial school are subject to approval by the state board of education pursuant to section 22-2-107. Services provided through such agreements may include, but are not limited to:

• (a) Educational services required to be provided under section 22-33-203 (2) and any educational services provided to at-risk students identified pursuant to section 22-33-202;

• (b) Counseling services;

• (c) Substance use disorder treatment programs;

• (d) Family preservation services.

• (e) and (f) (Deleted by amendment, L. 98, p. 570, § 3, effective April 30, 1998.)

(2) At a minimum, each agreement entered into pursuant to this section shall specify the services to be provided under the agreement, the entity that will coordinate and oversee provision of the services, and the responsibilities of each entity entering into the agreement. In addition, each agreement shall require each entity entering into the agreement to contribute the services or funds for the provision of the services specified in the agreement. The agreement shall specify the services or the amount and source of funds that each entity will provide and the mechanism for providing said services or funds.

(3) Each school district shall use a portion of its per pupil revenues to provide services under agreements entered into pursuant to this section for each student who is at risk of suspension or expulsion or who is suspended or expelled. In addition, the school district may use federal moneys, moneys received from any other state appropriation, and moneys received from any other public or private grant to provide said services.

(1) The general assembly hereby finds and declares that:

• (a) Colorado ranks fortieth in the nation in the school nurse-to-student ratio;

• (b) The federal center for disease control's healthy people 2020 recommended one school nurse for every seven hundred fifty general education students, but many school nurses in Colorado are responsible for as many as six thousand students, making it difficult to provide the social-emotional support necessary to students and staff;

• (c) In 2011, prior to the legalization of retail marijuana, almost forty percent of students surveyed reported having tried marijuana one or more times, with nine percent reporting that they had tried marijuana before age thirteen;

• (d) In addition, twenty-two percent of students reported using marijuana one or more times in the last thirty days, with six percent reporting that they had used marijuana on school property one or more times;

• (e) The legalization of retail marijuana is anticipated to increase the availability of marijuana to underage youth;

• (f) Marijuana use by minors can have immediate and lasting health implications, and many youth who engage in substance abuse develop or have underlying behavioral health needs;

• (g) School health professionals have already started to experience the results of marijuana as a newly legalized substance in increased visits to the health office and referrals from school staff; and

• (h) School health professionals are in a unique position to educate, assess, and treat youth who have substance abuse or behavioral health issues.

(2) The general assembly further finds and declares that a program to provide matching grants to education providers to enhance the presence of school health professionals in schools throughout the state will facilitate better screening, education, and referral care coordination for students with substance abuse and other behavioral health needs.

(1) (a) There is created in the department the behavioral health care professional matching grant program, referred to in this article 96 as the "program", to provide funding to education providers for the following purposes:

• (I) To increase the presence of school health professionals in schools to provide behavioral health care to students who have mental health, substance use or misuse, or other behavioral health needs;

• (II) To provide training and resources for school staff on the implementation of evidence-based programming on behavioral health education for all students;

• (III) To allow school health professionals to connect students with services that are provided by community-based organizations for treatment and counseling for students who need behavioral health care; and

• (IV) To provide behavioral health care services at recipient schools, including but not limited to screenings, counseling, therapy, referrals to community organizations, and training for students and staff on behavioral health issues.

• (b) An education provider that receives a grant under the program shall use the money to increase the level of funding the education provider allocates to school health professionals to provide behavioral health care to students prior to receiving the grant and not to replace other funding sources allocated to provide school health professionals for students. The education provider may use the money to contract with a community partner for behavioral health care services, including hiring private health care professionals, training, screening, and preventive supports. Additionally, the education provider may use the money to provide direct services or consultation by a school health professional through telehealth technology. The department shall administer the program as provided in this article 96 and pursuant to rules adopted by the state board.

(2) The state board shall adopt rules pursuant to the "State Administrative Procedure Act", article 4 of title 24, C.R.S., for implementation of the program, including but not limited to rules regarding:

• (a) The timeline for submitting applications to the department;

• (b) The form of the grant application and any information in addition to that specified in section 22-96-104 (2) to be included in the application;

• (c) Any criteria for awarding grants in addition to those specified in section 22-96-104 (3); and

• (d) Any information to be included in the department's program report in addition to that required in section 22-96-105.

(1) The general assembly hereby finds that:

• (a) Access to school-based primary health care for children and adolescents has been shown to increase the use of primary care, reduce the use of emergency rooms, and result in fewer hospitalizations;

• (b) High-risk students who use school-based health centers are more likely to stay in school and be available for instruction;

• (c) School-based health centers are effective at managing health conditions, such as asthma;

• (d) School-based health centers serve primarily low-income schools. The majority of students who attend schools with on-site health centers are from low-income families, are medically uninsured or underinsured, and qualify for free or reduced-cost school lunch.

As used in this part 5, unless the context otherwise requires:

• (1) "School-based health center" means a clinic established and operated within a public school building, including charter schools and state-sanctioned high school equivalency examination programs associated with a school district, or on public school property by the school district. School-based health centers are operated by school districts in cooperation with hospitals, public or private health care organizations, licensed medical providers, public health nurses, community health centers, and community mental health centers. The term "school-based health center" includes clinics or facilities authorized to provide clinic services pursuant to section 25.5-5-301, C.R.S., or authorized to apply for and receive medical assistance payments under a contract entered into pursuant to section 25.5-5-318, C.R.S.

(1) There is hereby created, in the prevention services division of the department of public health and environment, the school-based health center grant program, referred to in this part 5 as the "grant program", for the purpose of assisting the establishment, expansion, and ongoing operations of school-based health centers in Colorado. The grant program shall be funded by moneys annually appropriated by the general assembly specifically for said program.

(2) (a) Operators of school-based health centers may apply for grants for the benefit of school-based health centers. The grant program shall provide grants for school-based health centers selected by the division. The division, in consultation with school-based health centers, shall develop criteria under which the grants are distributed and evaluated. In developing the criteria for grants, the division shall give priority to centers that serve a disproportionate number of uninsured children or a low-income population or both and may award grants to establish new school-based health centers; to expand primary health services, behavioral health services, including education, intervention, and prevention services for opioid, alcohol, and marijuana, and other substance use disorders, or oral health services offered by existing school-based health centers; to expand enrollment in the children's basic health plan; or to provide support for ongoing operations of school-based health centers. None of the grants shall be awarded to provide abortion services in violation of section 50 of article V of the state constitution.

• (b)

• (I) On or before July 1, 2018, the general assembly shall appropriate seven hundred seventy-five thousand dollars to the department from the marijuana tax cash fund created in section 39-28.8-501 for the purposes of expanding behavioral health therapy, intervention, and prevention services for opioid, alcohol, and marijuana, and other substance use disorders pursuant to this subsection (2). The department shall prioritize funding to school-based health centers that serve communities with high-risk factors for substance abuse combined with limited access to treatment services according to state needs assessments, Colorado health indicator data, and national best practice trends.

• (II) Any unencumbered and unexpended money from an appropriation made pursuant to this subsection (2)(b) remains available for expenditure by the department in the next two fiscal years without further appropriation.

(3) The division shall specify and provide to potential grant recipients the following information:

• (a) Procedures and timelines by which an operator of a school-based health center may apply for a grant;

• (b) Grant application contents;

• (c) Criteria for selection, reporting, evaluation, and other criteria as necessary;

• (d) Criteria for determining the amount and duration of the grants;

• (e) Reporting requirements for grant recipients; and

• (f) Any other information the division deems necessary.

(4) Grant recipients shall submit reports to the division as outlined in the reporting requirements summarizing the use of the grant moneys.

(5) A grant awarded by the division shall be used for the school-based health center for the purposes stated in this part 5. The grants shall supplement existing funding sources for the school-based health center, such as federal funds, patient fees, public and private insurance, and grants and donations, including in-kind donations received from community hospitals, foundations, local governments, and private sources.