Integrated clinics:

1. Integrated clinics: Threat or Enhancement to Training? Cindy M. Bruns, PhD Association of Counseling Center Training Agencies – Baltimore, MD 2112

2. 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.

3. 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.

4. 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)

5. 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

6. 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

7. American College Health Association - 2010

8. AUCCCD Data on Collaboration and Integration What are we really doing out there?

9. 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%

10. 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%

11. 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 without needing additional informed consent? Yes 12.20% Yes but only with Psychiatry 6.34% No 81.46%

12. AUCCCD Data - 2011 Are you (the Counseling Center Director) the chief administrator over the health service? Yes 11.35% No 88.16%

13. 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?

14. 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?

15. 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

16. 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?

17. 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

18. 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.