Integrated health care: improving client care while providing opportunities for mental health counselors.

Integrated healthcare, the co-location of mental health and medical professionals within primary care settings, is an emerging trend. In essence, integrated care eases the access such that underserved primary care clients with mental health needs can receive treatment. Current models of integrated care are described, and strategies for mental health counselors' involvement within primary care settings are discussed.

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Of clients waiting to see primary care physicians, 60% to 70% need mental health services (Cummings, 1991); and of the roughly 40% who are referred to mental health professionals, only 10% follow up with appointments (Cummings, 2002). Evidence also suggests that 50% to 90% of clients with mental health needs rely solely on primary care physicians (PCPs) for services (Brody, Khaliq, & Thompson, 1997; Burns, Wagner, Gaynes, Wells, & Schulberg, 2000; Hemmings, 2000; Regier, Goldberg, & Taube, 1978). High utilizers of medical services, including people who frequently visit emergency rooms, often present with mental health and substance abuse issues (Lepine, 2002; Mehl-Madrona, 1998). Even more startling, in a research review of suicide among the elderly, Conwell (2001) found that 43% to 76% of the older adults who committed suicide had visited their PCP within one month prior to their death. Consequently, proper treatment for clients with mental health concerns within general medical practices is questionable at best, if not negligent (Lesser, 2000).

Reliance upon PCPs for mental health concerns continues despite a growing body of evidence suggesting that those who receive counseling and other mental health services experience physical as well as mental health benefits. For example, children who received psychological services for behavioral and psychosomatic complaints experienced fewer emergency primary care visits and utilized less medical services one year after treatment (Finney, Riley, & Cataldo, 1991). There is also evidence that group counseling increases immune system functioning (Fawzy et al., 1990), the length and quality of life of those with cancer (Shrock, Palmer, & Taylor, 1999; Speigel, Bloom, Kraemer, & Gottheil, 1989), and pregnancy rates for infertile women (Hosaka, Matsubayashi, Sugiyama, Izumi, & Makino, 2002).

This information is known to many mental health counselors. Although the importance of clients' emotional well being and its link to physical health has been espoused for years (Hafen, Karren, Frandsen, & Smith, 1996), professionals have been frustrated in knowing how to increase mental health access to those in need (Cummings, 2002). Mental health parity, which requires insurance companies to provide equitable coverage for both physical and mental health care, has recently been the primary target for increasing such access. Unfortunately, mental health parity may not be a panacea, as some professionals believed. For instance, insurance companies, if forced by government regulation to provide equal coverage, will pass the additional costs to the consumers through higher premiums and co-payments, which will again limit access to mental healthcare, albeit indirectly (Cummings).

As such, the primary purpose of this manuscript is to call mental health counselors' attention to an emerging trend, integrated care, and suggest strategies for becoming involved in an integrated care practice. Two general models of integrated care are reviewed to demonstrate how integration is currently structured. Most importantly, practical suggestions and strategies for mental health counselors and counselor educators will be introduced to enhance client care but also provide insight into new employment opportunities for mental health counselors.

INTEGRATED CARE

Integrated care, an emerging trend, offers much promise to clients and all healthcare workers (Brody et al., 1997; Kates, Crustolo, Farrar, & Nikolaou, 2001). Integrated care is the increased collaboration of mental health professionals within primary care settings. More specifically, integrated care is most effective when services are provided via co-location, that is, when mental health counselors work in the same offices with PCPs. In this type of integrated arrangement, PCPs and mental health professionals consult regularly throughout the day about clients' needs and will, in some situations, see a client together to help determine the most appropriate treatment plan. For example, in one large health maintenance organization, PCPs and psychologists share offices. Consequently, the professionals are successfully identifying 90% of the primary care clients who need mental health services, and of those clients, 85 % are receiving treatment (Cummings, 2002). Reasons for this success include the collaboration between the two healthcare providers and more importantly, clients' following through with treatment, perhaps because PCPs can introduce clients to the mental health professionals on staff, instead of referring them to outside agencies.

Integrated care research has demonstrated significant positive results, including: decreased depression and increased quality of life of older adults relative to a treatment-as-usual control group (Unutzer et al., 2002), increased anxiety-free days for people with panic disorder (Katon, Roy-Byrne, Russo, & Cowley, 2002), decreased in-patient psychiatric admissions (Kates et al., 2001), and decreased client distress levels (Kates, Crustolo, Farrar, & Nikolaou, 2002). In addition, evidence suggests that clients prefer to receive mental health counseling within their primary care setting (Arean & Miranda, 1996; Brody et al., 1997; Hemmings, 2000), report less stigma about receiving mental health services, and feel reassured knowing that their PCP is involved in treatment (Vega, Moon, Aspy, & Ross, 1999). Finally, in a recent review of over 60 integrated care studies, Blount (2003) found that, in general, integrated care produced improved clinical outcomes, increased client and provider (e.g., PCP) satisfaction, and improved cost effectiveness. Reasons for the successful outcomes include the ease of access of mental healthcare within a familiar setting, but also include PCPs involvement in clients' mental healthcare needs as well as PCP's relief in knowing that they have in-house support to handle their clients' mental health needs. These findings are important considering the emphasis being placed upon increasing mental healthcare access while simultaneously attempting to control health care costs.

MODELS OF INTEGRATED CARE

Integrated care is emerging in many different practices, including all four primary areas of medicine: (a) family practice, (b) internal medicine, (c) obstetrics, and (d) pediatrics as well as specialty areas such as oncology and cardiology. The models range in levels of integration, but each shares the characteristic of co-location of physicians and mental health professionals. These integrated care agencies are typically classified as either non-targeted or targeted (Blount, 2003). Non-targeted practices provide a broad array of services to clients with various health-related needs and concern. Examples of non-targeted practices include independent family practices and public health centers, Targeted integrated care practices provide services to clients experiencing specific concerns (e.g., substance abusing pregnant women, cancer patients).

Non-Targeted

Non-targeted integrated care practices are characterized by close collaboration between physicians and mental health professionals who consult regularly with each other throughout the day, often informally, about different client concerns and needed strategies (Blount, 2003). In this model, mental health professionals often take a case management approach to mental healthcare. Physicians remain in charge of the patients' physical well being while the mental health professional assesses for mental illness, links clients with appropriate services, and provides time-limited therapy.

Lesser (2000) describes an example of a non-targeted integrated family care practice that serves a diverse community comprised mostly of working-class clients who do not qualify for government subsidies but rely largely on managed care health plans for services. The practice began with a physician and a social worker, both of whom had considerable experience and a strong belief in the need for a biopsychosocial model of healthcare. The practice has now expanded to include a second social worker, a psychologist, a consulting psychiatrist, and a nurse practitioner. Within this practice, comprehensive family medical care and mental health services are provided. Mental health services include: individual, group, and family counseling; support groups (e.g., recovery form alcohol and drug abuse); psychoeducational groups (e.g., parenting classes); and case management. The majority of clients utilized the mental health services offered when recommended. As evidence for this model's success, Lesser found that from all of the patients seen during the practices' 7 years of existence, only three patients had missed their scheduled appointments with their in-house mental health professional. All of the clinicians are licensed; therefore, most are enrolled on the various insurance panels. Funding for most services is obtained through insurance reimbursement.

Many non-targeted integrated practices operate similarly to the one described by Lesser (2000). However, there are some integrated care practices that exhibit notable differences. For example, in one integrated public health center, a questionnaire screening for depression, alcohol and substance abuse, suicide risk, and Bi-Polar disorder is administered to each new client (Mims and Rodriguez, 2003) in order to ensure that clients' mental health needs are not overlooked, even when they are presenting with other issues (e.g., stomach problems, headaches). The completed instrument is then given to the attending physician prior to the client's physical exam; and when mental health needs are discovered, the mental health professional is called into meet with the client to provide a more detailed assessment and, if needed, arrange for counseling appointments or an appropriate referral. Due to the large volume of clients seen at the center, the mental health professionals provide time-limited brief counseling, crisis management, client education, and case management services. The center is funded by various sources including state and county funds, grants, and Medicare and Medicaid reimbursement. In an effort to reduce the power hierarchy so often perceived between physicians and mental health professionals and to create a team feeling among staff, all of the professional staff are called clinicians: the physicians are called primary care clinicians (PCCs) and the mental health professionals are referred to as behavioral health clinicians (BHCs).

Targeted

Targeted integrated care practices are different from non-targeted practices in that services are specialized to treat a specific health-related concern (Blount, 2003). Patients who meet the criteria for specialized services (e.g., panic disorder, chemically dependent pregnant women) are referred to a treatment team with specialized knowledge in that particular area. Targeted treatment teams are often made up of nurses, social workers, counselors, and psychologists, and the services they provide include counseling, education, transportation, and case management. Generally, there is ongoing collaboration between the treatment team members and the PCPs. Oftentimes, the treatment team is located within the same offices or in an adjacent wing of the healthcare facility (McLeod, Budd, & McClelland, 1997); however, some agencies contract with outside mental health professionals who then make frequent visits to the PCP's office to provide treatment (Katon et al., 1999).

One example of a targeted program is a cancer patient support program (CPSP) located in a University Medical Center and is comprised of a licensed psychologist, director, two master's level counselors, and 25 volunteers (MeQuellon, Hurt, & DeChatelet, 1996). In addition, there are approximately 75 community volunteers who help with fund raising to support the program. The purpose of the program is to offer a wide array of emotional and behavioral services to cancer patients and their families including: an orientation program; individual, group, and family counseling; case management; psychoeducation; and child care. The psychologist is primarily responsible for psychological evaluation, counseling, program coordination, research, and consultation with oncologists, with counselors' being responsible for coordinating volunteers and counseling practicum and internship students, providing individual and group counseling, and orientating new patients and their families. In this targeted care practice, a brief orientation program is composed of a tour of the facility, including the examination and chemotherapy rooms; a description of clinical procedures; information such as pamphlets containing important phone numbers and visiting hours; and a question and answer session for clients and their families Research conducted at the center (McQuellon et al., 1998) found that those who received the orientation experienced lower state anxiety, less emotional distress and depression, and greater overall satisfaction with services than those who did not receive orientation. Approximately 90% of the funding at this center comes from fundraisers using community volunteers, grants, an endowment, and donations; but it is supplemented by insurance reimbursement for counseling services (McQuellon et al., 1996).

IMPLICATIONS FOR MENTAL HEALTH COUNSELORS

Regarding integrated care, the types of activities performed will vary depending upon the agency's philosophy, the staff and their needs, the type of agency, and the skills and qualifications of the mental health professional. For example, a mental health counselor working in an independent family practice could be responsible for more case management type activities than a counselor working in a grant-funded program targeted toward helping clients and families cope with cancer and its treatment. However, the following implications seem fairly consistent when working in an integrated care setting.

1. Mental health counselors who wish to become involved in integrated care settings should find ways to network with physicians. Strategies include renting office space in or near a medical practice complex and visiting local PCPs to offer consultation on a fee-for-service basis (Lesser, 2000). We have found that many collaborative arrangements are created when mental health professionals initiate or suggest integrated care to their personal physicians or physician friends. Furthermore, many cities have health education centers dedicated to providing continued education for healthcare providers. Contacting these centers can help mental health counselors find like-minded professionals interested in pursuing integrated care.

2. To be attractive to PCPs, it is important for mental health counselors to obtain licensure and get instated on insurance panels. Mental health counselors who can receive third party insurance reimbursement may be more likely to be employed by PCPs because of the potential for generating revenue. Mental health counselors also need to advocate to federal legislators to make licensed mental health counselors in private practice eligible to receive Medicare and Medicaid reimbursement. Currently, besides physicians, only licensed social workers and psychologists are eligible under these plans. Therefore, it is important for mental health counselors to keep abreast of public policy and to write their representatives in Congress indicating support for vital counselor-friendly legislation (see American Mental Health Counselors Association [AMHCA], 2003).

3. Mental health counselors can secure grant funding to initiate entry into integrated care. Grant funding can provide the seed money needed to pay mental health counselors' salaries until insurance reimbursements are established. In order to develop grant writing skills and learn more about funding opportunities, mental health counselors are encouraged to contact their local universities to inquire about workshops, classes, and books.

4. Integrated care practices are often fast paced environments where treatments are usually brief. Therefore, it is important for mental health counselors to be skilled in assessment to ensure that clients are accurately diagnosed and the appropriate treatment is provided. Using brief standardized screening instruments as well as conducting structured interviews is important in these settings. Particular attention should be paid to disorders which are often under diagnosed in primary care settings (e.g., substance abuse, depression, anxiety disorders). Often times, PCPs do not have the time or training to conduct thorough assessments of mental and emotional disorders; therefore, skill in this area can be particularly helpful to PCPs, not to mention clients. After diagnosis, mental health counselors must be skilled and comfortable leading time-limited structured groups, conducting relaxation training, providing psychoeducation, and offering brief therapy on an individual and group basis as needed.

5. Mental health counselors in a primary care setting must also be willing to work with a broad, general population across a variety of disorders. According to Kates et al. (2001), counselors will see clients across a broad range of age, ethnicity, and presenting problems. Effective mental health counselors will be able to assess and recognize a variety of mental heath issues, and will be able to connect with both children and senior citizens from various cultural backgrounds.

6. A good working relationship among the mental health counselor, PCP, and other professionals is a critical component of successful integrated care (Thrower & Wallenius, 2003; Vega et al., 1999). Mental health counselors must be flexible and willing to collaborate with people from multiple disciplines while maintaining an attitude of openness and understanding. When working in a fast paced environment, mental health counselors must be able to clearly and concisely state their point and listen to other clinicians' points of view as well. Mental health counselors must also realize that the transition to integrated care takes time. Many primary healthcare professionals are not familiar with mental health counseling or integrated care, as such; it may take time for mental health counselors to become accepted by other staff members.

7. Mental health counselors must also be comfortable working within a biopsychosocial model of care, which includes medications. They should keep up to date with current pharmacological treatments for different disorders and be able to recognize side-effects of these different medications. Collaborating with PCPs in identifying problems with medications (e.g., non-compliance, intolerance, side-effects) can be particularly helpful for clients and staff.

8. Case management is another need within integrated care practices. As case managers, mental health counselors link clients with needed service providers within the community. Referral services may include adult or child day care agencies, local and state government aid agencies, housing agencies, and long-term mental healthcare. Often case management is the missing link in a primary care practice because many clients do not know what services are available or they are simply apprehensive about negotiating the bureaucracy of public aid. With support from mental health counselors, clients are more likely to obtain needed services.

9. Mental health counselors may also take the responsibility for conducting research into the effectiveness of integrated care. Important variables to monitor include: number of hospitalizations, long-term care referrals, emergency room visits, and number of office visits, especially unscheduled office visits. Because admission to hospitals, long-term care, and emergency room visits are extremely costly, monitoring these incidences can provide valuable information into the cost effectiveness of integrated care. Appointment compliance as well as client, physician, and counselor satisfaction are other legitimate areas for investigation into the effectiveness of integrated care.

10. Educators can assist mental health counselors interested in working in integrated care in several ways. First, when teaching an assessment course, educators can ensure that their students are practiced in using brief screening instruments such as the Symptom Checklist-90-R (Derogatis, 1994) and the Substance Abuse Subtle Screening Inventory-III (Miller, 1997). Second, program course work needs to include the knowledge base that provided students with a basic understanding of psychopharmacology, including the side-effects of different medications. Third, generic assignments in such classes as group and family counseling could be specifically designed to address integrated care issues. For example, in a group counseling class, interested students could develop structured, psychoeducational groups for clients and families dealing with health-related matters such as heart disease, Alzheimer's, or cancer. Fourth, students should get the opportunity. possibly through role play assignments, to practice using brief therapy modalities. Fifth, educators can create assignments in their classes that require students to advocate for their profession by writing their state and federal representatives urging them to include mental health counselors as providers in health reform legislation. Finally, educators should establish internship agreements with integrated healthcare practices.

CONCLUSION

Because of improved clinical outcomes, high client/clinician satisfaction ratings, and cost savings, integrated care may well be the way of the future. Integrated care creates a synergy that benefits all involved: Physicians get the support they need to manage the burgeoning number of primary care clients presenting with mental health issues, mental health counselors are given the opportunity to work in unique settings that reach many people who normally would go untreated and, most importantly, clients receive integrated care which could significantly enhance the quality of their lives.

Despite the many benefits of integrated care, several challenges exist. Ethical issues, for instance, may emerge within the integrative care framework (Lesser, 2000). At times, physicians and counselors may have conflicting opinions about what is best for clients. As such, it is important for physicians and mental health counselors to discuss their ethical standards in order to understand where conflict may exist and determine legitimate strategies for negotiating problems while maintaining ethical integrity. Naturally, this conversation needs to happen early in the collaborative arrangement to insure compatibility between the PCP and mental health counselor. In addition, mental health counselors may feel isolated working within an integrated care practice because many current practices employ only one mental health professional (Kates et al., 2001). It is important for mental health counselors to be able to discuss problem cases and concomitant treatment strategies with other mental health counselors. Therefore, mental health counselors should seek outside supervision, especially peer supervision with other counselors working within other integrated care practices. Furthermore, it should also be noted that many of the current integrated practices include PCPs working with social workers and psychologists, not mental health counselors. It behooves mental health counselors, then, to understand that they need to aggressively seek ways to enter this promising market. Indeed, the purpose of this manuscript is to prepare mental health counselors for integrated care.

We end this article with a client's story which exemplifies the power of integrated care. At a recent conference, a client spoke of her experience in a small family medical practice where she received mental health counseling. She reported that, despite having been encouraged by her PCP to seek counseling for several years, she had not agreed until a mental health professional was hired within her PCP's office. Then she presented for mental health counseling because: she knew where the office was, she knew where to park, she knew the people at the front desk and they knew her, and she knew her PCP would be integrally involved in her care. Ultimately, for this particular client, the co-location of her mental health professional and physician was the incentive she needed to attend to her mental health needs. In our experience, this case is not isolated, and it is hoped that mental health counselors will soon play a vital role in the emerging trend of integrated care.

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Jana Bowling Aitken is a counselor with Western Carolina Treatment Center in Asheville, NC. Russ Curtis is an assistant professor of Counselor Education at Western Carolina University, Cullowhee, NC. E-mail: [e-mail]