integrated clinics:

INTEGRATED CLINICS:

Threat or Enhancement to Training?

Cindy M. Bruns, PhD

Association of Counseling Center Training Agencies – Baltimore, MD 2112

DISCLAIMER

Oops! Please don’t mistake me for an expert. I just

proposed this presentation in the spirit of ACCTA

volunteerism. I do, however, work in an integrated clinic and am fairly competent at

literature searches.

LEARNING OBJECTIVES

1) Participants will be able to describe at least 3 potentially problematic issues related to integrated medical and counseling clinics.

2) Participants will be able to describe at least 3 potentially beneficial outcomes of integrated medical and counseling clinics.

3) Participants will be able to describe at least 2 methods of facilitating collaboration in a multidisciplinary setting.

INTEGRATED CARE OUTSIDE THE UNIVERSITY SETTING

Have been discussions in the literature for the last 2.5 decades

Definitions vary widely:• Biopsychosocial treatment• Professionals from different disciplines working

closely to provide continuity of care• Behavioral or mental health consultants working

with physicians• Direct (assess to answer a specific question, chart

answer)• Informal (sit in on staffings and provide expertise)• Collaborative (combines direct, informal, and often

psychotherapy)

WHY INTEGRATIVE CARE IN THE “REAL” WORLD?

Mental health concerns constitute a significant percentage of presenting issues in primary care settings

Increased focus on biopsychosocial aspects of disease

Increased focus on wellness and prevention

Recognition of the psychological aspects of compliance with treatments and interaction of mental and physical health concerns

Lack of training for health care providers with respect of psychological functioning

WHY INTEGRATED SERVICES AT

UNIVERSITIES?

Reduction of barriers (i.e., less stigma about going to the health center vs the counseling center)

Mental health concerns are large percent of presenting complaints at health centers

Ease of cross-referrals

Elimination of duplicate resource expenditure

Students may be less confused about where to go for what

Many of same reasons for integrating care in the “real” world

AMERICAN COLLEGE HEALTH ASSOCIATION -

2010

WHAT ARE WE REALLY DOING OUT

THERE?

AUCCCD Data on Collaboration and Integration

AUCCCD DATA - 2011

My counseling center collaborates with Student Health Services

Not at all 3.90%

A little 15.12%

A fair amount 46.34%

Extensively 34.63%

AUCCCD DATA - 2011

Is your center located adjacent or near a student health service?

Yes 57.11% No 42.89%

Is your center located in a student health service building?

Yes 35.15% (up from 15% in 2009) No 64.85%

Is your center administratively integrated within a health service?

Yes 25.36% (up from 15.6% in 2009) No 74.64%

AUCCCD DATA - 2011

Do you and you Student Health Services share an electronic medical records system?

Yes 16.01%

No 83.99%

Do you and you Student Health Services share access to your counseling records withoutneeding additional informed consent?

Yes 12.20%

Yes but only with Psychiatry 6.34%

No 81.46%

AUCCCD DATA - 2011

Are you (the Counseling Center Director) the chief administrator over the health service?

Yes 11.35%

No 88.16%

CONCERNS ABOUT INTEGRATION

Being over-taken by medical/disease model

Records/confidentiality

Loss of autonomy

Budget/resource allotment

Having a director who doesn’t understand counseling

Loss of counseling center identity

Basic philosophical differences…clients versus patients, etc.

Others?

POTENTIAL TRAINING DRAWBACKS

Training program seen as “extra” or “expendable” item in the budget when times are tight

Subtle or not so subtle pressure to change training or treatment philosophy toward medical model/problem-solving approaches

Interns exposed to “turf” wars or triangulation

Others?

POTENTIAL BENEFITS TO TRAINING

Exposure/introduction to behavioral health issues and practice

Development of cross-discipline consultation skills

Develop broader conceptualization skills using multiple perspectives

Education regarding interaction of medical diagnoses with psychological effects

Greater education about medication uses and side effects

POTENTIAL BENEFITS CONTINUED

Experience with truly coordinated care of a client/patient

Learning how to navigate medical system in order to advocate for clients in a supported and supervised setting

Develop appreciation for the difficult job of medical providers, nurses, etc.

Others?

IMPORTANT CONSIDERATIONS PRE-

INTEGRATION

Talk, talk, talk, talk• Goals of integration• Roles• Training• Philosophy• Legalities (e.g., records, confidentiality)

Respect, respect, respect

Clarity of structure

Common goal: Student Service

IMPORTANT CONSIDERATIONS POST-

INTEGRATION

Talk, talk, talk, talk

Respect, respect, respect

Regular Multidisciplinary Team Meetings

Shared vision statement

Individual department mission statements related to vision

Continued clarification of roles, laws, ethics, boundaries, etc.