Youth Behavioral Health Coordination Project

Program Overview

In January 2015, stakeholders from across the CPAA region identified improved behavioral health care coordination for children as a high need in local schools and undertook an effort to reduce the number of children with unmet behavioral health needs. The result was the CPAA’s Youth Behavioral Health Coordination Pilot Project. Currently, the Project is being implemented in primary and secondary schools in Cowlitz, Mason, Thurston, and Wahkiakum counties. The goal is to identify children with behavioral health challenges as early as possible, connecting them to treatment services and appropriate community-based interventions. Through criteria developed by cross-sectoral leaders throughout the region, four schools were chosen based on high ACEs scores, a mix of rural and urban sites, school interest in participating, and available community resources. In the 2016-2017 school year, over 200 students have been referred to the program and 131 received counseling and other behavioral health services.


• Identify children with behavioral health challenges (mental health and substance use disorders) as early as possible in both education and health care settings
• Connect vulnerable children with community-based interventions and treatment services
• Decrease the number of school-aged youth with unmet behavioral and physical health needs through improved care coordination by schools, pediatric primary care physicians, and behavioral health specialists
• Prevent teen suicide and suicide attempts through early intervention and care coordination


In the 2016-2017 school year, a total of 215 students were referred to the program across all four sites and 131 received or are currently receiving services. If successful, the YBHC Project will result in improvements in a number of outcomes that can be captured by existing school data sources, including: number of absences, number of discipline incidents, and measures of individual academic achievement. As yet, these data have not been collected in a way that permits assessing changes over time that are attributable to the program. While quantitative outcome measures are not yet available, interviews with program staff and others identified a number of encouraging initial results: immediate access to behavioral health services, improvements in school attendance, connection to resources, reduced stigma, recognition of importance of mental health, and a feeling of support for school staff.

Service Delivery Model

Early warning signals (e.g., absenteeism, declining grades, etc.) are used to identify students for referral-based screening. In addition to students self-referring, identification is done by existing interdisciplinary teams that can include the principal, school counselor, school nurse, school psychologist, and teachers.

The school-based behavioral health provider (BH provider) screens students using standard tools such as the Strengths and Difficulties Questionnaire (SDQ), the Global Appraisal of Individual Needs Short Screener (GAINSS), and Pediatric Symptoms Checklist. These tools help identify the types of clinical, behavioral, social/emotional, academic and/or basic supports needed by the student. Based on a student’s assessments, the appropriate behavioral health services are provided.

  • The BH provider also helps coordinate services, working in partnership with school nurses, counselors and other school staff. Their activities can include:
    • Attaining confidentiality release forms to share information across systems;
    • Identifying and coordinating referrals;
    • Serving as the information conduit between all those serving the student and providing feedback loops between educational, clinical, and community settings;
    • Helping the student find a health home; and
  • Notifying provider practices in the area about the pilot and their role as the lead case manager for students attending that school.


Behavioral Health Providers, Community-Based Social Service Organizations, Educational Service Districts, Medicaid Managed Care Organizations, Pediatricians, Primary Care Providers, Public Health, Schools, etc.

Lessons Learned

• Engage partners early to ensure a common understanding of vision, roles, and responsibilities
• Integrate behavioral health providers with the rest of the school
• Create a comprehensive, integrated system of support
• Establish systems for data tracking and evaluation

Next Steps

CPAA will work with project partners to build on lessons learned, conduct ongoing project evaluation, and improve data analysis and reporting. Further developing data reporting capabilities to show improvements in outcome metrics over time is of particular interest. Outcome metrics currently being discussed pertain to behavioral health treatment and school-based metrics such as attendance, discipline, and academic achievement.

CPAA Contact

For more information, contact Kennedy Chesoli, Director of Programs: