Ngaramadhi Space: An Integrated, Multisector Model of Care for Students Experiencing Problematic Externalising Behaviour

Partners and Service Delivery

NS was built through, and on, partnerships developed over time involving community paediatrics, the school, allied health, and the social care sector, and was overseen by the Wouwanguul Kanja Committee (Figure 4). Key stakeholders from the education sector included the school director, principal, and a networked specialist facilitator, with each holding a unique strategic role. For instance, the school director provided governance and direction to multiple schools within the community and afforded executive level endorsement of the NS model of care, while the principal provided leadership within the school and played an integral role in embedding NS within the school’s existing processes and culture [72, 73]. The networked specialist facilitator was a specific position within the Department of Education (DOE), whose role centred on building connections between the education sector and other agencies, including the health sector [74]. Furthermore, the school, due to its specialised nature, provided the model with teachers and therapists skilled in managing behavioural issues.

Figure 4

From the health sector, a community paediatrician, with support from the Director of Community Paediatrics and the Child and Family Health Management team, was integral in driving the formation of the multidisciplinary clinic, providing paediatric developmental and behavioural expertise, and establishing an evaluation process. The Youthblock Youth Health Service (Youthblock) providing the team with a specialist youth health nurse and pathways to support young people e.g. drug and alcohol counselling, sexual and reproductive health services [75]. A child and adolescent from SLHD was partnered with to establish a system whereby the paediatrician could consult with the psychiatrist for advice and support regarding students [76].

The NS model required the skills of a social worker. Initially a non-governmental organisation called Family Referral Service (FRS), now called ‘Family Connect and Support’, was partnered with to assist families in connecting with local support services [77]. Later, the school contracted a social worker for this role. Senior clinicians from the HHAN team had a broad understanding and knowledge of the community and provided support to the NS team [78].

Students at the school were identified as requiring trauma-informed speech pathology (SP) and occupational therapy (OT). The school contracted these therapists using a combination of public and school funding.

Wouwanguul Kanja Committee

Since its conceptualisation in 2015/2016, community members and stakeholders played an active role in informing the NS model. After the piloting phase (2016–2019), a community reference group called the Wouwanguul Kanja Committee was formally established. The Aboriginal community members decided on the structure of the committee agreeing that it was to be kept small and include representatives from the Aboriginal community and NS team. The Aboriginal members provided insight into culturally safe ways of working including a ‘whole of child and family’ approach and having services co-located and integrated at the school [67]. The community members communicated the importance of the different sectors working together by not only providing a multidisciplinary assessment but also collaborating after the assessment to ensure that outstanding matters could be discussed.

All members of the committee were actively involved in designing the evaluation process, ethics applications, reporting of results and preparing scholarly articles. The committee met regularly and developed agreed upon terms of reference. The community members expressed a need to scale up the NS model because the holistic approach was seen as an effective way of improving access and engagement with health and education services [67, 79].

Referrals and Pre-Assessment Information Gathering

YGS is a specialised behavioural school and acceptance is based on a referrals process. Enrolment at the school and participation in NS were voluntary. During the six-week school orientation period, verbal and written information about the NS assessment was provided. Written permission was obtained from parents to attend the assessment and for information sharing across the sectors. To enable provision of family-centred care, when concerns were raised about siblings of students, they were also offered a NS assessment.

Following the pilot phase of the NS assessment, a consistent approach to the pre-assessment phase was established (Figure 5). A ‘School Health Team’ was developed and included the paediatrician, youth health nurse, social worker, and school counsellor. An initial ‘Case Review Meeting’ was held to discuss referrals and to facilitate information sharing. If a student was engaged with an external paediatrician or psychiatrist this clinician was considered to be the lead clinician. Before proceeding with a full NS assessment, the lead clinician was contacted to see if the assessment would be beneficial. If the lead clinician felt that a full assessment was appropriate, then this would be arranged, and the lead clinician was offered an opportunity to be present for the assessment either in person or using videoconferencing. If the lead clinician did not think a full assessment was necessary, a partial team assessment with a social worker, school counsellor and youth health nurse would be offered to the family. A partial team assessment involved a current psychosocial history without a full medical review.

Figure 5

Collating and sharing information prior to the NS assessment was a key component of the model. Information sharing amongst agencies is necessary when providing high-quality health and social care and the team were guided by NSW privacy-related legislation [80]. The school counsellor summarised information about the family, assessment results, and education support. The class teacher provided current information about the student’s academic skills, behaviour and SEWB by completing a Canadian ADHD Resource Alliance (CADDRA) report and a Strengths and Difficulties Questionnaire (SDQ teacher version) [81, 82]. The paediatrician provided a summary of available health information. This preparation led to a better understanding of the student and how to approach the assessment.

Maintaining a ‘medical home’ with the family general practitioner (GP) was an important consideration in developing the model of care [83]. Parents were asked to share written information about NS with their GP to help build this connection. Families also required GP referrals for the clinic and to see the SP and OT. A letter communicating the assessment findings of the NS assessment was provided to the GP as well.

Multidisciplinary Assessment

The full multidisciplinary assessment was conducted with the student and parent by the School Health Team (Figure 5). After introductions, consent and confidentiality were verbally established. The team approached the student’s health and psychosocial history flexibly, taking into account the student’s behavioural needs and the family dynamics. During the assessment the student was seen on their own by the youth health nurse or paediatrician to conduct an adolescent psychosocial assessment (HEEADSSS assessment), hearing, vision and dental screening, and complete a physical examination including anthropometric measurements [84]. A parent and student SDQ were also completed.

The team then discussed the presenting issues and formed a joint and holistic understanding of the student in line with the family’s priorities. Where possible, students were linked into existing services such as established community paediatric clinics or mental health services. When this was not possible, other avenues within the community were explored. Towards the end of the assessment consent for the separate processes of sharing medical information and participation in the research component was discussed and completed. After the assessment a comprehensive letter was compiled primarily by the paediatrician with input from other team members. Box 1 illustrates a typical patient journey through NS.

After the Assessment

Students were discussed at the subsequent Case Review Meeting to consider any outstanding issues. Once in every school term the NS team met with school staff to facilitate communication and to understand the student’s progress. The psychiatrist attended these meetings either in person or using videoconferencing to provide insight into further diagnostic or management options.

Employee Wellness

Working in psychological trauma services can have an impact on staff wellbeing [70]. Participating in a multidisciplinary model helped alleviate individual burden of care. In addition, regular professional development sessions and support networks were established to promote connectedness across the sectors. Staff were also aware of how to access free employee counselling.

Evaluation Methods and Initial Outcomes

NS is a complex intervention where students have diverse needs and attend a multidisciplinary assessment [85]. NS is being evaluated using a mixed methods design and these results will be reported in later manuscripts using the model of care described in this paper. Preliminary quantitative evaluation has shown that students had multiple unmet physical health, mental health, and social needs. Attendance at the NS was high and there was a statistically significant improvement in teacher reported scores using the SDQ [in print]. A qualitative study examining how the education and health sector can work in partnership including facilitating factors and barriers is currently underway and will be reported in a later manuscript. The authors acknowledge that because this was a pilot study, data on longitudinal outcomes were not evaluated. The research team are designing an implementation study with the following outcome measures:

Engaging and empowering people and communities

The NS model of care was effective in engaging and empowering people and communities. This was achieved through effective community consultation which led to the development of a culturally-safe and multidisciplinary model. This approach aligns with the Closing The Gap Implementation strategy which emphasises the role of formal partnerships and shared decision-making with the Aboriginal community [68].

YGS is unique and has an important role in the community, acting as an endpoint for students experiencing significant behavioural issues. The trajectory for these students is poor and the community saw a need to change this pathway. A holistic approach was considered important in addressing the multifactorial issues that resulted in the problematic behaviour. For the Aboriginal community it was critical that the SEWB of students was recognised, a term which reflects the important connection between physical, mental and emotional health with social, spiritual and cultural wellbeing [12, 14, 18]. Amongst the Aboriginal community SBHC is an effective way to address inequity with collaborative partnerships between the health and education sector that seek to understand the ‘whole of the child and family’ valued [67, 79]. NS was governed by a community reference group, Wouwanguul Kanja, that oversaw all aspects of the design and evaluation of the initiative. This active participation from the community led to acceptance of the model along with calls to scale up the model so that other students could benefit from the approach [67, 79]. It is important for this level of community participation to be maintained and improved upon as the model evolves and is scaled up.

Coordinating services within and across sectors

The NS model achieved coordination within and across sectors through sharing of information, joint assessments and case review meetings. Working across sectors allowed timely and effective management of learning and behavioural difficulties. For example, health staff could directly contact teachers about the effectiveness of medication changes. This level of communication meant that the likelihood of complex students slipping through the system was reduced and allowed staff to present consistent messages to students and families [53].

Collaboration across sectors often presents challenges. Time is required for teams to understand each other’s role, work through conflict, develop trust and effective communication [86, 87]. Some issues that arose included an understanding of who the ‘leader’ was and assigning responsibility for tasks [88, 89, 90]. There were matters arising from changes in staffing and changes in stakeholder capacity as well. The impact of these incidents was minimised by taking a stepwise approach to implementing the model and documenting roles and responsibilities [89].

Strengthening governance and accountability

Over many years the NS model was able to strengthen governance and accountability across sectors. The health and education systems are complex and hierachical systems. Navigating these systems and bringing them into alignment required persistence, relationship development and time with decision-making by School Health Teams often requiring endorsement at a high executive level [53].

The direction provided by the Wouwanguul Kanja community group helped embed NS within the school. Through this avenue a MOU was agreed upon. In the context of NS, creating a MOU helped legitimise the way the various sectors worked together in view of setting a precedent for other models when scaling up the initiative. Further to these processes, administrative and educational meetings were set up for the whole team and supervision was strengthened by linking the school social worker with the HHAN care coordination team. These are small steps towards true integration and further high-level executive support is required within the departments of health and education.

Reorienting the model of care

Health and education are closely linked across the lifespan. Healthy students are in a better position to learn and students with higher education levels are more likely to engage with healthy behaviours throughout their life [11, 91, 92, 93]. The NS model is a school-based, holistic, and integrated care initiative. By reorientating health service delivery to schools access to care is improved thereby providing an opportunity to intervene and interrupt the trajectory of those attending YGS.

Delivering health services at schools is convenient for students and families while allowing health staff to leverage of the trust students have with the school. This approach has been shown to improve engagement, particularly for priority populations such as ethnic minority groups and those from low socioeconomic areas [34, 43, 47].

Creating an enabling environment

For the previous four strategies to become operational, it is important to create an enabling environment. NS was embedded within the overall HHAN framework [62, 63]. This strategy helped bring together key stakeholders to undertake transformational change [65]. This was a complex task involving changes to the way staff from the various sectors worked together. The school principal played an important role in establishing a welcoming environment for the different sectors to connect and in embedding the NS processes within the school’s workflow and culture. The NS team needed to learn how to adapt to changing circumstances, pivoting to meet the needs of the school and community, particularly during the COVID19 pandemic. The multidisciplinary team shared a common purpose and demonstrated a willingness to work flexibly and come to the school to improve access and engagement of students. The team continued to revise and refine the model of care, a process that occurred over years so that person-centred care could be optimised. The team developed a MOU to provide structure to how the sectors worked together including how the model of care could be sustained. An evaluation process was embedded in the model so that the quality of service delivery could be improved upon, a process which continues to be developed for future studies. NS is a pilot model of care and to ensure that it can be scaled up further commitment at a state-level from health and education is required.