AISD’s Therapy Provider Struggles to Meet Demand Amid Mental Health Crisis

Art by Zeke Barbaro / Getty Images

Margaret Bachicha, an assistant principal at Dobie Middle School, didn't know that the Austin Independent School District had hired Gramercy Specialty Clinic as its new mental health services vendor until Decem­ber 2021, almost a year after the new contract began. "We went from having [previous vendor] Vida Clinic on our campus, [which] was providing services for hundreds of our kids on our campus, to nothing," Bachicha said.

"That has been very difficult in a time when we needed mental health services, even more than we did in previous years," Bachicha continued. Communication with Gramercy was so poor that counselors at Dobie are no longer making referrals to the contracted provider, she said, instead opting for outside providers such as Lone Star Circle of Care and Integral Care.

Gramercy, an Austin-based outpatient behavioral health care company, replaced Vida Clinic as AISD's vendor for mental health services at the beginning of March 2021. As the school board prepared to vote on the new contract during a meeting in January 2021, then-Director of Health Services for AISD Alexandra Copeland assured the trustees that there would be no disruption of services.

In fact, "if we do not move forward at this time, there will be an interruption," Copeland warned, as trustees voiced concerns about whether the clinic would be able to ramp up to meet demand in a district that serves more than 75,000 children. At the time, Gramercy employed only 10 licensed professional counselors who operated primarily through teletherapy services across Texas. Its proposal to the district outlined a plan to increase its staff to meet demand over a six-month period.

"Constant Coordination"

Records obtained from the district show that trustees' fears may have come true. Between March 1, 2021, and June 1, 2021, the first three months of Gramercy's operation in AISD, 483 students were referred to Gramercy for mental health services. During that period, Gramercy saw only 54 students through telehealth, and fewer than five in person on an AISD campus. (To remain compliant with federal student privacy laws, AISD does not report numbers fewer than five students.)

Chart by The Austin Chronicle

Elizabeth Alegria, CEO of Gramercy Specialty Clinic, said the data from the first several months of its operation in AISD is "no longer representative of where we are now," saying that the company has since boosted the number of children who were able to get appointments after beginning the referral process. She said one new hurdle is that the referral and intake process for getting an appointment has changed since Vida Clinic was the vendor; it's now a two-step process that requires parents or staff to submit a referral to Gramercy electronically, and then make phone contact to make an appointment.

"Part of the concern relates to how the organizational design of the referral/intake process has changed, and part of it may have to do with how effectively this new process information is being communicated across a massive scope of people," Alegria said. Although the company has tried to implement some marketing strategies, including materials fixed with QR codes that link to intake and referral documents in both English and Spanish, Alegria said the challenge of raising awareness of the services "is a massive project that requires constant communication and coordination on a macro level."

She alluded to another challenge – finding enough therapists when demand is at an all-time high, and attracting them to Austin as the cost of living here has skyrocketed. "In an effort to recruit highly trained, expert staff, we began to offer bilingual and multilingual providers housing that our company would provide to diminish their housing costs in a very expensive market," Alegria said. "We understood that the housing demands in Austin were a deterrent to some providers we interviewed across our state."

Even with these efforts, it's clear the number of students being placed with therapists hasn't nearly reached the levels Vida had delivered. A separate records request revealed that Gramercy received only 1,073 referrals for services from students under its contract through March 25 of this year. By comparison, Vida Clinic provided counseling to 4,879 individuals through its school mental health centers within AISD between September 2019 to March 2020, the point at which schools shut down due to the COVID-19 pandemic.

Thereafter, Vida Clinic also operated via a teletherapy service model; prior to the end of its contract, it was operating at 45 campuses through school-embedded clinics, and seeing clients in 79 schools via teletherapy, using more than 50 full-time and part-time therapists. According to the district, on-site services from Gramercy are only housed in 13 AISD schools.

Allen Weeks, executive director of Austin Voices for Education and Youth, a nonprofit that works with school communities to develop leaders and increase enrollment and achievement, said the district should have been able to predict that Gramercy would not be able to fulfill the extent of the contract from the proposal it presented. "It was clear that Gramercy did not have the staffing and they did not have experience with public schools," Weeks said. "They said they would be able to replace services at 45 campuses but the budget in their proposal did not reflect that at all."

Lotta Needs, Lotta Money

Gramercy's contract is worth $3.7 million, paid with dollars designated for services to those without health insurance, for the initial 17-month period between February 2021 and June 2022. Three one-year renewal option periods are each worth $2.2 million, for a total of more than $10 million over five years. Current AISD Health Services Director Alana Bejarano clarified that because those services operate on a fee-for-service model, the district won't necessarily just hand that money over to Gramercy unless the company bills for that entire amount.

Even so, she said, the district does want to ensure it's utilizing the full scope of the dollars it has allocated for mental health services at a time, during a global pandemic, where mental health has deteriorated across the board. "That's clearly not happening. Gramercy invoiced the district only $125,628 during a period spanning more a year since the company's contract began, indicating a very low level of services." She said the decline in numbers may be because the counselors at the campus level are "doing the meat of the work" and reserving therapist capacity for "Tier 4" students and staff with the greatest need of counseling support. She acknowledged that perhaps that Tier 4 designation needs expansion, and perhaps the district's mental health services need a media campaign to raise awareness.

"Most counselors know how to mandate those services; they don't want to refer to Tier 4, if that's not what's best for the student," Bejarano said. "I'm hoping that the general public might understand that our layers of in-house professionals are doing a wonderful job in fixing those before they escalate to a Tier 4."

But that doesn't fully explain why the number of referrals decreased so greatly during a time when mental health issues across the country reached perhaps an all-time high. Nor does it explain the drastic discrepancies administrators are seeing on AISD campuses.

At the January 25 meeting of the AISD Board of Trustees, Chief Academic Officer Elizabeth Casas said access to on-site School Mental Health Centers made the district unique, and that the district would strive to preserve that feature. But since Gramercy took over, that benefit has all but disappeared, said Heather Merritt, chair of special education at Travis Early College High School, where an SMHC is housed. Whereas she considered Vida's provider at her campus to be a part of the school community, Merritt said that hasn't been the case for the stretched-thin Gramercy staffer at her school.

Both Bachicha and Merritt said some mental health assistance is provided by other district partners like Communities in Schools, a nonprofit that offers counseling and support groups in addition to other resources. However, Bachicha said, CIS isn't designed or intended to handle the full scope of mental health needs on AISD campuses. The fact that resources are so scantily available at her campus, a Title I school with a large population of low-income and at-risk students, is for Bachicha proof enough that resources are not being allocated appropriately.

Bejarano said the district plans to put out another call for services soon – not to replace Gramercy, but to expand mental health services within the district. "That means we want Gramercy to also provide, but we'd like to reach out to the community because they're in such short supply [of therapists], so we'd like to cover all of our bases," she said. "There may be many [requests for proposal] expanding services; we'd love to see this program really developed."

Kids "Parenting Themselves"

AISD opened its first School Mental Health Center in 2012 at Crockett High School, with services provided by Lone Star Circle of Care. The goal of the program was to offer financially sustainable mental health services to students, staff, and family members without relying on grant funding. Vida Clinic, founded by Elizabeth Portman Minne in 2015, took over the program shortly after its inception.

Under Vida's stewardship, the clinics expanded into numerous other schools. However, the district health services under Copeland became worried about the company's financial sustainability when it switched to a fee-for-service model in 2019 due to the loss of a significant grant source. Under the new model, insurers paid for services for those with coverage, the district for those without.

As Copeland explained at a board of trustees meeting in September 2020, Vida Clinic's operation under the new model made it difficult to reach mutually agreeable contract terms. "The district and community has always respected Vida Clinic's dedication," read an agenda item for that month's meeting. "However, the implementation of the fee-for-service model with Vida Clinic had its challenges ..." The district stated that the goal of issuing a new request for proposal was to secure a vendor that was able to deliver quality services under this model and to implement a cap on the amount of billable services not directly related to clinical therapy.

Four companies, including Vida and Gramercy, submitted proposals; by that 2020 board meeting, only Gramercy was left as an option. Two proposers were dismissed after an initial round of interviews, and Vida Clinic withdrew for unspecified reasons. The district ultimately postponed its vote until early 2021 and restarted the RFP process, but Gramercy again was the sole finalist.

Ken Zarifis, president of the AISD employee union Education Austin, said teachers have been complaining of rampant (and often violent) behavioral issues in classrooms since the beginning of the fall semester, likely due to trauma experienced during the pandemic. Bachicha, who's worked at Dobie Middle School for four years and AISD for 22, said the poor state of mental health among students is apparent on her campus. "We're dealing with fights constantly," she told the Chronicle. She also believes the behavioral issues are a direct result of the pandemic: "They basically have been home for two years, parenting themselves because their parents were working."

Ken Zarifis (Photo by John Anderson)

In addition to claiming nearly 1 million American lives over two years, COVID has damaged the mental health of people in all walks of life. In children, the effects have been both stark and well-documented. According to a March 2022 report put together by the Austin-Travis County Com­munity Advancement Network, the suicide rate for 15- to 19-year-olds has increased 75%. The suicide rate for children aged 10 to 14 was previously too small to measure, but that age group has now entered the chart: "That means children are beginning to consider suicide as their only option earlier than they had in the past," the report reads.

Even before the pandemic, mental health issues were common among young people in Austin. According to AISD's mental health report for the 2018-19 school year, 1 in 5 adolescents have a serious mental health condition at some point in their life, with 1 in 8 experiencing depression that can eventually lead to self-harm. Half of all mental illness is evident by the age of 14.

Zarifis, who's fielded complaints from his members regarding Gramercy, said his biggest takeaway is that the district took away an effective service to begin with and should have been willing to financially back Vida Clinic as its preferred and proven provider. "When you find someone that you trust with mental health issues, it's important to stick with it," Zarifis said. "When you put dollars in front of people, instead of people in front of dollars, you end up with decisions that hurt people."