What can athlete’s foot teach health professionals about the effective and efficient provision of counseling services? Plenty, according to Russ Curtis.

Most people who contract athlete’s foot don’t hesitate to pick up a topical medication from their local grocery store or at Walmart, tossing the spray or cream into their shopping cart along with a gallon of milk, cans of soup, some snacks, greeting cards, a package of batteries, the latest best seller, detergent and various items for the home.

But imagine, says Curtis, if those same sprays and creams were sold only in stand-alone stores that specialized exclusively in treatment of the skin fungus. Suddenly, the stigma level for seeking treatment would rise greatly. Individuals would duck in and out of the store, hoping not to be noticed by passersby or, even worse, identified by their neighbors. Others, too embarrassed to run this risk, would forgo treatment altogether and pin their hopes on the condition clearing up on its own. Many whose problems could successfully be addressed with minimal treatment early on wouldn’t seek help until their condition grew much worse, leading to the necessity of more radical, lengthy and extensive treatment.

Unfortunately, it’s probably all too easy to see that if you substitute “minor mental health problem” for “athlete’s foot” in the scenario Curtis describes, you get a relatively accurate picture of why many people avoid counseling. That’s why Curtis and a number of other counseling professionals are advocating for integrated care, a model of treatment that allows clients to sidestep much of the stigma attached to mental health, normalizes access to behavioral health services and treats people before their problems grow too large.

“Integrated care is essentially the colocation of physicians with mental health care providers, working dynamically and consulting together throughout the day to best help clients,” says Curtis, an associate professor in the counseling program at Western Carolina University (WCU).

“’One-stop shopping’ is something we’re seeing just about everywhere, and that’s where health care is going too,” continues Curtis, an American Counseling Association member who infuses integrated care into the counseling curriculum at WCU. “People prefer the one-stop setup. It decreases the stigma of receiving counseling when it’s wrapped up as part of a visit to your primary care physician.”

The degree to which physical and mental health services are integrated within individual medical practices varies depending on the collaborative model being used, as does the exact role of the counselor (often referred to as the “behavioral health provider” in the parlance of integrated care). Some of the more common duties include providing assessment services, psychoeducation, brief therapy and case management, consulting with physicians and nurses, and acting as a liaison to the consulting psychiatrist and outside mental health community. A counselor in an integrated care setting essentially serves as the on-site mental health specialist.

Integrated care does have its detractors and skeptics within the counseling profession. “Some mental health professionals get offended and think we’re trying to replace their services by promoting integrated care,” concedes Eric Christian, a licensed professional counselor who helps agencies develop integrated care sites as the integrated care coordinator for the Mountain Area Health Education Center (MAHEC) in Asheville, N.C. “But integrated care is a more population-based approach to mental health. We’re meeting clients where they tend to go for help — their primary care physicians. It does not replace specialty mental health care or substance abuse care requiring extensive therapy, but rather fills a service gap along a continuum of health care services. Integrated care offers an opportunity to deal with people’s mental and behavioral health issues when they’re mild or moderate rather than waiting for people to qualify for community mental health services only as things get much worse.”

The rationale for integrated care

Researchers have found that up to 60 percent of patients’ visits to their primary care providers have no biological basis, Christian says. According to one study conducted in 1991, 80 percent of patients with psychological distress present to primary care with unexplained physical symptoms.

“When doctors perform tests and everything comes out normal, that’s a good time to have the counselor talk to the patient and find out what else might be going on. How are things at home? At work? Have they been laid off? Clearly, those stressors can play a role in headache or chest pain or other physical conditions the person is experiencing,” says Curtis, who worked in mental health before becoming a counselor educator and completed his final internship at a medical center that provided integrated care.

A 2001 study by Yeates Conwell of the University of Rochester Medical Center Department of Psychiatry found that primary care physicians identified only 40 percent of those patients who needed mental health services; of those patients who were identified, only 10 percent sought mental health treatment. Various other studies have revealed that between 50 percent and 90 percent of referrals to behavioral health practitioners outside of the medical clinic do not result in therapy.

Says Christian, “Part of the stigma, especially for someone new to having a mental health issue, is that if you’re given an outside referral by your physician, the implicit message is, ’Your mental health issues are not even dealt with here. You need specialty care.’”

By having a behavioral health professional working closely with doctors on site, Christian says, integrated care models not only help prevent many people with mental health needs from falling through the cracks but also wipe away much of the stigma that might otherwise prevent these clients from accepting or following through with treatment.

Another argument for integrated care, Christian says, is that while more than 70 percent of medications for treating anxiety, depression and attention-deficit/hyperactivity disorder are prescribed in primary care physician settings, in most cases, patients aren’t receiving the recommended behavioral health treatment to complement these medicines. In integrated care settings, however, counselors can address behavioral health concerns with these clients and check in with them about medication adherence and side 
effects between physician appointments. “Integrated care offers an opportunity for the whole person to be treated in one location,” Christian says.

Even so, Curtis admits integrated care might be a foreign realm for many counselors. Some balk at the thought that their interactions with clients in integrated care will mainly involve brief interventions and quick assessments rather than traditional counseling sessions. Christian and Curtis, who have presented together on the topic of integrated care, say some counselors regard it as “therapy light.”

“Mental health professionals sometimes roll their eyes when we talk about brief sessions,” Curtis says, “but there’s evidence suggesting that the approach is effective, and I’m still not sure who created the 50-minute session. If you’re a counselor and you’re partial to the wood-paneled office, fish tank, fern and the 50-minute session, you’re going to have trouble with this model.”

That would be a shame, Curtis continues, because he believes counselors can excel in integrated care settings, thus demonstrating to doctors and patients/clients the valuable contributions counselors can make to an individual’s overall health and well-being.

“That would be good for our profession,” he says. “Counselors have a great opportunity to make an impact in this setting. There are lots of private physician offices out there, and that’s where folks go to get their mental health needs met because it’s whom they trust. In these settings, we can work with folks briefly before their problems get severe. It’s a little bit of that wellness model we talk about in the counseling profession. That’s some of the value of integrated care.”

“We’re (counselors and physicians) clearly trained very differently, but we need to work collaboratively to make sure our clients have the best care, because emotions and behaviors play a huge role in our physical health,” Curtis says. “Clients and physicians both like the integrated care setup, and I think counselors could do well in this setting. The biggest obstacle is our mind-set — breaking out of that traditional counseling box that we’ve created for ourselves and our clients.”

Offering a more complete picture

An LPC and private practitioner in Bristol, Va., Rick Carroll doesn’t shy away from outside-the-box thinking when it comes to counseling. So when three doctors who wanted their medical practice to provide holistic care approached Carroll roughly two years ago and asked if he could help them with patients experiencing unexplained medical symptoms, he signed on.

Carroll began screening the patients for a range of factors, including family dynamics, social issues, substance abuse, exercise, diet and spiritual well-being. “As a result, C-Health (the medical practice) started getting a more complete picture of their patients,” says Carroll, a member of ACA. “People often come to the doctor thinking that if they can just get that stomach pain or back pain taken care of … They don’t understand that the physical, the mental and the spiritual are often connected.”

While still maintaining his private practice, Carroll consults closely with C-Health in a partly integrated system. Carroll has a separate office across the street from the medical practice, but their Instant Messaging and e-mail systems are linked. C-Health and Carroll share a networked computer system, and Carroll has the ability to put in electronic progress notes, select and document diagnoses, choose billing codes and so forth. The two days a week Carroll is at his office (he also provides counseling services for a Children’s Advocacy Center), he stops by C-Health to speak with the medical staff directly. Carroll also has access to notes on the patients, including any medications they are taking.

“The doctors and nurses defer to me when it comes to treating that person psychologically,” he says. “It’s been a very humbling experience to have medical professionals grab me and say, ’Hey, I need some help here.’ At the same time, I’ve learned an awful lot from them. It’s been a good match.”

While C-Health’s five doctors and seven nurses have some basic training in psychology, Carroll regularly queries them about the issues they could use some insight on and offers in-services as needed. Among the topics he has covered: dealing with ADHD, identifying possible signs of domestic violence, recognizing stress brought on by the economy, looking for instances of cutting or self-harm and recognizing signs and symptoms of sexual abuse. “Now they’re (the medical staff) looking for signals, cues and signs that there’s something going on beyond the person not sleeping well,” Carroll says.

This type of collaboration has been a win-win-win for the medical staff, the patients/clients and Carroll. “People trust their doctors, and if the doctors are able to pick up on something that’s not medically oriented — ’Is there any stress in your life?’ — they’re able to introduce me to the situation,” Carroll says. “They’ll tell the patient, ’This person is part of our team. He provides another avenue to get you better.’ One of the biggest benefits for the medical practice is that it doesn’t have to see people for situational-specific depression and anxiety as much. That frees the doctors up to see other patients.”

In the region where Carroll and 
C-Health are located, coal mining is still a big industry, and the strenuous work often results in a high level of pain for the miners. The miners who receive pain medications through C-Health must attend a pain management support group led by Bill Haynes, an LPC and ACA member who is a colleague of Carroll’s. Held at the medical practice, the group explores topics such as identifying support systems and recognizing how stress can exacerbate pain. Carroll does individual work with these types of clients.

Carroll also leads patient groups and provides psychoeducation for C-Health. For example, C-Health is starting a special program for diabetics and wants these patients to learn about stress management, so Carroll will present monthly workshops.

According to Carroll, approximately 90 percent of his client base originates from his collaborative relationship with C-Health.

Finding an ’in’

According to a study published online in Health Affairs in April 2009, two-thirds of the primary care physicians surveyed didn’t have access to mental health specialists because of barriers such as insurance restrictions or a lack of such professionals in the area. In referencing the survey, Rodger Kessler, director of the American Academy of Family Physicians’ Collaborative Care Research Network (CCRN), stated that mental health is the most difficult specialty for family physicians to access. On top of that, he said, when physicians refer patients to outside mental health providers, it results in care being initiated in only 20 to 40 percent of cases. Driven in part by those numbers, CCRN is currently pursuing practice-based evidence to support the theory that a treatment model combining mental health, substance abuse and physical health services will produce better outcomes than the traditional referral system.

The integrated care model isn’t widespread at this point, so formal avenues for funneling counselors directly into these settings aren’t abundant. Fortunately, say Christian and Curtis, medical health professionals are increasingly recognizing the value of collaborating closely with behavioral and mental health professionals. This means many primary care physicians, pediatricians and other medical health professionals are open to counselors approaching them about implementing a system of integrated care.

“There are lots of grassroots ways to do this,” Christian says. “Counselors might approach their own doctor or their child’s pediatrician with the idea. What’s most important is that you show them how you can function in their format, in their environment. Initially, suggest the opportunity to shadow doctors for a while and let them know how you could interact with their patients. See where you might be able to plug in as a counselor and how that would free the physician up to move on to other patients.”

Christian also recommends that counselors look for medical practices launching new programs for a particular segment of patients. For example, he says, some medical practices have special programming and/or dedicated clinic time for patients with diabetes, and 11 to 15 percent of these patients are diagnosed with major depression, while many others have depressive symptoms. “A counselor could approach a medical practice and say, ’Instead of just referring these clients to me, it would be nice to be able to say that you have someone on staff who can talk with them about their depression or speak with newly diagnosed patients about lifestyle and behavior changes to help address their illness,’” Christian says.

In addition, specialty environments are tailor-made for integrated care, he says. For instance, counselors might work in a cancer patient support program to help with psychosocial issues and depression, to meet with family members and to provide grief work.

During his internship, Curtis roamed throughout the hospital, providing support wherever it was needed, from the cardiovascular unit to the emergency room. “A lot of times, patients’ mental health needs would be met in the emergency room,” he says, “and the ER doctors really seemed to like having us there.”

Another natural fit? “Integrated care is really nice for pediatric settings,” Christian says, “because most kids can benefit from some level of behavioral health intervention during the course of their development, and with this model, it can be dealt with at the point of care.”

Curtis believes the timing is right for more counselors to make inroads in integrated care. “Doctors are hearing a lot more about the connection between mind-body wellness,” he says. “Counselors have been talking about wellness for a good while, and now there’s a lot of discussion about positive psychotherapy. Evidence is showing that if we can elevate people’s moods, that can play a part in improving their health.”

Confronting challenges

Although the market may be ripe for counselors to enter integrated care, they should be aware of some of the inherent challenges. High on that list is reimbursement issues.

“Reimbursement criteria vary so much from state to state and from one insurer to another,” Christian says. “Patients may not have a behavioral health benefit or realize it is being used during the visit, so disclosure and consent for services is very important. In addition, the primary care facility may be overwhelmed with having to negotiate billing for behavioral health services, so a lot of planning has to be done, and the practice manager has to be on board.”

Typically, counselors in integrated care settings might apply traditional therapy billing codes and use their National Provider Identifier (NPI) number. But some counselors may be able to take advantage of “incident to” billing, meaning the behavioral health provider’s services are rendered as a physician extender for certain patient conditions. In these cases, the physician’s NPI is used for billing, and master’s-level counselors receive a higher reimbursement level for their services.

In North Carolina, Health and Behavior Assessment/Intervention codes have been developed as part of newer Current Procedural Terminology codes for use with Medicaid patients. The behavioral health codes allow counselors to address behavioral health issues associated with the management of chronic medical conditions such as diabetes and fibromyalgia, smoking and tobacco use and so forth. The codes are used “incident to” the physician and do not require that the patient be diagnosed with a mental health problem.

Certain cost increases are also associated with integrated care, which scares off some primary care providers, but Curtis says research shows that integrated care models actually result in overall health care savings of 20 to 40 percent. He points out that by catching patients’ behavioral and mental health problems earlier in the process, integrated care reduces the number of hospital admissions and emergency room visits.

The thought of working in integrated care appeals to many counselors because of the variety, the opportunity to work with other types of health care providers and the fact that not every client is presenting with high-end mental health issues, Christian says. As appealing as these attributes may sound in theory, however, some counselors struggle with the transition to a less structured, less formal, less traditional counseling environment. “Again,” Christian says, “this model doesn’t work for counselors who are rigid about having 50-minute sessions. It also requires someone who has some business sense and is willing to address administrative issues. And you have to be comfortable with interruptions by other clinicians who may need your assistance.” Because integrated care is still relatively new, he says, counselors must also be willing to embrace a trailblazing role at most medical offices rather than expecting to walk into a fully functioning system that is free of any kinks.

“You have to be able to roll with ambiguity,” Curtis adds, “and you have to be flexible. You need to be someone who can be present and calm with clients, yet quick and to the point when talking with a physician.”

Working in a truly collaborative environment might be a major adjustment for many counselors, Carroll says. “In this setting, you have to understand that you can’t do it all yourself. You have to be able to surrender that mind-set and ask for help.”

At the same time, he says, counselors should be ready to justify why they are offering a different diagnosis than the doctor. “I have rarely encountered any power struggles,” Carroll says, “but to assert yourself without ticking others off, to traverse that slippery slope, is more an art than a skill.”

In the face of any challenges, Carroll says, it is most important to buy into the effectiveness of the integrated care model and remember that everyone on the team is working toward a common goal. “Integrated care is something that really benefits the clients. And, ultimately, the clients’ needs trump our needs.”

Jonathan Rollins is editor-in-chief of Counseling Today. Contact him at jrollins@counseling.org.

Implications for counselors

Although Russ Curtis already infuses integrated care into the counseling curriculum at Western Carolina University (WCU), the associate professor and ACA member hopes to one day establish an integrated care elective or track for counseling students. Curtis currently has three students doing internships with integrated care facilities thanks to Eric Christian, a graduate of the WCU counseling program and the integrated care coordinator for the Mountain Area Health Education Center in Asheville, N.C.

Curtis and Christian, who copresented on the topic of integrated care at the 2009 ACA Annual Conference in Charlotte, N.C., have identified several implications for counselors who would like to practice in an integrated care environment:

  • Network with physicians.
  • Set up practices in medical office parks.
  • Obtain licensure and advocate for LPCs to receive Medicare reimbursement.
  • Become familiar with brief assessment tools to identify substance abuse, depression and anxiety disorders (including postpartum problems).
  • Develop proficiency in providing brief therapy.
  • Become familiar with pharmacology, including common side-effects of different medications.
  • Take classes/workshops in physiology and health psychology, such as smoking cessation, fibromyalgia, chronic pain and irritable bowel syndrome, because all have behavioral health components.
  • Become a generalist — a counseling professional who is able to enter any situation and provide some input.

Implications for counselor educators:

  • Introduce integrated care to students in the first clinical mental health counseling class.
  • Develop a specialty for students in integrated care.
  • Talk to physicians and hospitals about internships for counseling students.