Total health care

When Russ Curtis visits his primary care physician (PCP) for his yearly checkup, the physician checks his blood pressure and his weight. She listens to Curtis’ heartbeat and asks if he’s been having any pain. She also screens for substance abuse and depression.

It hasn’t always been the norm for family doctors to screen for things such as depression, so many advocates consider that a step forward in linking medicine and mental health. Unfortunately, that’s often where the ball stops.

If Curtis’ responses indicated he was dealing with symptoms of depression, the doctor would likely give him a referral to a mental health practitioner within his insurance network. And given that Curtis is a counselor himself, he wouldn’t stop short at the idea of visiting a mental health professional for help.

For many other individuals visiting their PCPs, however, the reasons not to follow up on that referral may outweigh the incentives of taking that next step. Perhaps the patient is embarrassed to tell his family that he is going to a counselor. Perhaps he feels pressed for time to make calls to see which counselor is accepting new clients. Maybe he simply can’t take off from work for yet another appointment at a different office. As a result, he oftentimes doesn’t get the care he needs.

Curtis, an associate professor of counseling at Western Carolina University, points to research indicating that only 40 percent of clients who need mental health services are identified by PCPs. Worse, of those individuals who are identified by PCPs, only 10 percent follow through and seek mental health treatment.

PCP offices have been referred to as our nation’s de facto mental health centers, Curtis says, and with good reason. Research indicates that as many as 70 percent of primary care visits have a psychological basis, he says. Perhaps not surprisingly then, PCPs provide 50 percent of all mental health care, and those same physicians prescribe 67 percent of all psychoactive drugs, Curtis says.

Eric Christian, a counselor and the integrated care manager at Community Care of Western North Carolina, says research shows that 80 percent of patients prefer to get their behavioral health care from their family doctor.

That number doesn’t surprise Craig Travis, a licensed counselor and psychologist who says going to see a physician is less daunting for most people than seeking help from a mental health professional. In addition, the American Counseling Association member says, patients often develop close relationships with their PCPs. “Because it’s such a trusted and noble profession, patients talk with their doctors about what’s going on in their lives,” says Travis, who serves as director of behavioral sciences at Grant Medical Education, the education department within Grant Medical Center, an OhioHealth hospital in Columbus, Ohio. “The physician might say, ‘I think it would be helpful if you go talk to someone,’ and then they send the patient somewhere else.”

In an optimal scenario, Travis says, the physician would introduce the patient to a mental health colleague located in the same office, allowing the patient a chance to seek counseling in a safe and familiar environment.

Considering that 8 in 10 people prefer to visit their doctors for behavioral health needs and that one of counseling’s mantras is “meet clients where they are,” Christian and Curtis say the conclusion is simple: Counselors need to start meeting clients at the doctor’s office. After all, Curtis says, true health care happens when both mind and body are cared for and seen as inherently connected.

A range of options

Curtis and Christian co-edited the book Integrated Care: Applying Theory to Practice, which was published by Routledge last year. Together, they define integrated care as “the seamless and dynamic interaction of primary care physicians and behavioral health providers working within one agency providing both counseling and traditional medical care services.”

If integrated care is viewed on a continuum, integration in its slightest form can include focused collaboration between clinicians and physicians with shared referrals, says Teresa Jacobson, who is working as a counselor at a community mental health agency in Ohio and earning her doctorate in behavioral health from Arizona State University. Also on that continuum, a counselor and physician could be “co-located,” working in the same building and perhaps collaborating but still operating as separate offices.

“On the other side of the continuum, full integration would include mental health clinicians working with medical physicians and providers, utilizing a shared electronic medical record, unified treatment plan and goals, and immediate collaboration,” says Jacobson, who founded and facilitates ACA’s Integrated Care Counseling Interest Network. “The mental health clinician — often referred to as a behavioral consultant in an integrated care setting — may be asked to join a physician and patient in an exam room with what Russ Curtis refers to as a ‘warm handoff’ in which conversations between the three parties aid in developing collaborative goals and [a] treatment plan.”

Jacobson says a reverse model of integration happens when physicians or nurse practitioners join a community mental health agency. The agency where Jacobson works is in the process of transitioning into such a model. Christian adds that reverse models of integrated care can be particularly helpful because individuals with severe, persistent mental health needs often have unmet physical health care needs as well. Bringing a physician on board at a mental health agency can link those clients to the primary care they may be lacking.

According to Jacobson and Curtis, there is research showing that people with severe and persistent mental illness die 25 years earlier on average due to physical health complications, likely because their physical health needs go comparatively unmet with so much focus being paid to their mental health.

Just as a variety of integrated care models exist, there are also a variety of integrated care settings in which counselors or other mental health clinicians might work. Among those Jacobson mentions are pediatric or primary care settings, emergency departments, specialty offices such as obstetricians or endocrinologists, nursing homes, fitness and nutrition settings, community mental health agencies that are transforming into Medicaid “health homes” and hospice care.

A counselor’s role in an integrated care setting can run the gamut. Travis says common tasks include providing mental health assessment and diagnosis, offering crisis intervention, consulting with physicians, making treatment suggestions, providing patient education and screening to see if a referral should be made for more specialized mental health treatment.

Curtis adds that the length of counseling sessions in integrated care settings will depend on whether other behavioral health providers are present. If multiple clinicians are on staff, one counselor could be doing traditional counseling sessions, while another remains on call to complete assessments, screenings and consultations.

The benefits of having a counselor in an integrated setting are numerous, Jacobson says. “Counselors in integrated care will be on the front line with medical professionals, working with children, adolescents, adults and the elderly, many of whom do not follow through on referrals, some who don’t feel comfortable telling their primary care physician [about mental health issues] or some who decide to take a pill without counseling intervention,” she says. “Think of the years of emotional pain that can be avoided if a counselor can identify trauma early on. Think of the turmoil that can be avoided if a child with special needs was able to talk about peer victimization and ostracism. Think of those who are coping with chronic pain, but an X-ray does not show ‘proof’ of the pain. Think of the elderly who are often isolated and neglected who could spend a few minutes to talk about grief, aging, loneliness, ailments, lack of purpose or death. Many of these folks are only treated by primary care providers or specialists. If a counselor in an integrated care setting reaches them and they need more than brief sessions, a referral can be made.”

Knocking down silos

After earning his master’s degree in counseling from the University of North Carolina at Charlotte, Curtis landed his first counseling job as an intensive case manager at a mental health center in South Carolina. In working to coordinate his clients’ medical and mental health care, he learned something that sticks with him to this day. “I found that comprehensive care was effective and that without it, we were really missing out on giving clients the full care they needed,” says Curtis, who co-facilitates ACA’s Integrated Care Counseling Interest Network with Jacobson.

Curtis gives the example of a patient who goes to her primary care doctor and says she is having heart problems. The doctor’s office runs tests but can’t find anything wrong, so the doctor orders more tests and perhaps even prescribes a medication without screening for mental health issues. All the while, Curtis says, the issue may be panic disorder, not heart trouble. In addition to missing the underlying issue, the situation would be frustrating and, likely, depressing for the patient, while also ramping up the cost of treating the patient.

Those results are typical when mental health care is separated from physical health care, says Travis, adding that “siloed care” is simply not efficient. What is efficient, he says, is when counselors and doctors can work together to treat the whole patient.

At Grant Medical Center in Columbus, Travis teaches family medicine residents the psychosocial aspects of medical care and how to screen for, assess, diagnose and treat psychological disorders. He also supervises counseling and psychology students who work as part of the center’s integrated care environment.

Mental and behavioral issues often go hand in hand with medical issues, Travis says. For example, good physical health often hinges upon making sound behavioral choices such as eating well and exercising.

When psychological issues are present — especially issues that go untreated — they can quickly complicate any physical issues. For example, Travis says depression is highly correlated with a number of medical illnesses. He refers to findings just released from a 12-year study by the University of Queensland in Australia that indicate that having depression may double the risk of stroke for middle-aged women.

Jacobson provides additional evidence of the interrelated nature of illness and depression. She says 15 to 20 percent of patients with cardiac problems, 25 percent of patients with diabetes and 25 percent of people with cancer have depression, while 20 percent of those with respiratory illness have concurrent depression and/or anxiety.

“If depression is not treated,” Travis warns, “often the comorbid physical illness is not controlled.”

Curtis agrees and mentions a patient who is both diabetic and depressed. With depression in play, he says, the patient may not possess sufficient motivation to follow through on the nutritional advice his doctor provides.

When depression is present but untreated, research indicates that the cost of treating a medical issue goes up, Curtis says. Depressed patients use three times the health care services and have seven times more emergency department visits than those without depression. Further complicating the issue, Curtis says, is that depression is diagnosed accurately in primary care settings only 50 percent of the time.

On the other hand, Curtis says, when physical and mental illnesses are treated together, as is the case in integrated care settings where counselors and physicians work side by side, studies have shown that treatment is less expensive overall and outcomes are better.

Kathleen Sebelius, secretary of the Department of Health and Human Services (HHS), alluded to the same point in an interview that ran in the June 2012 issue of Counseling Today. She referenced how the Affordable Care Act would help join behavioral health services with the rest of the health care system. “Integrating services,” Sebelius said, “is increasingly recognized as important to achieving both the quality and cost-savings goals of health reform.”

One-stop shopping

Breaking down those silos and reconnecting the mind with the body offers the potential for better care, Jacobson says. “For so long, the mind has been treated separately from the body. Physicians, specialists and mental health clinicians have been working in silos in a fragmented system. The lack of collaboration has often led to confusion, inefficiencies, mixed messages to clients, prescription duplication issues, double [or] triple work and, many times, little improvement. If we work together, we can learn from each other and collaborate to help each client accomplish their goals.”

Jacobson points to Cherokee Health Systems in Tennessee, which began integrating mental health and primary care as early as 1984, as an example of success. In a newsletter last year, the HHS Agency for Healthcare Research and Quality indicated that Cherokee Heath Systems has realized benefits including reduced emergency room use, fewer inpatient admissions, reduced specialty referrals, enhanced patient satisfaction, increased primary care use and improved patient outcomes.

Add to that list of benefits the potential for prevention, Curtis says. “Integrated care moves closer to prevention in that it can identify mental health issues through routine screening at medical visits and, hopefully, provide education and treatment so that the issue does not become overwhelming to the client,” he says. “For instance, if every expecting parent is given information throughout the pregnancy and after [delivery] about postpartum mood disorders (PMD) [such as] anxiety, depression and psychosis, parents will not be as freaked out about it if PMD issues happen. And they can access treatment more confidently — and, hopefully, earlier — because they were told to be on the lookout for such symptoms. We could use this same example with anxiety, depression, posttraumatic stress disorder, substance abuse, etc.”

Another plus for integrated care is how well it aligns with the way society operates today, Travis says. When people go to “superstores,” they might buy a birthday present, get their eyes checked, have their prescriptions filled, get their oil changed, go grocery shopping and grab a Starbucks coffee on their way out. People have come to expect that level of one-stop shopping in every aspect of their lives, Travis says. Integrated care settings provide that by allowing individuals to see their doctors and counselors in one visit. “It’s meeting the patients’ needs,” Travis says. “Make it about them and easy for them.”

Integrated care is also a godsend for clients who feel a stigma attached to seeking counseling. In these settings, they can visit their doctor and then also speak to a counselor without anyone else knowing. Any remaining stigma can be further eroded when physicians in the integrated care setting normalize the idea of counseling, Travis says. For instance, a doctor might say, “Let me introduce you to one of my colleagues — our counselor on staff. This is who we doctors go to talk to when we’re stressed out.” A similar introduction from a trusted source opens the door wider for the patient to talk to a behavioral health professional without making a separate appointment or going to a different location.

“Mental health not only becomes a routine part of visits to a doctor, but physicians erase any shame or embarrassment [about seeing] a therapist,” Jacobson says. “With mental health clinicians under the same roof as medical doctors, the behavioral and mental health component is not just convenient, but encouraged as a part of normal remedial and preventive care.”

Some counselors worry that working alongside doctors might mean their counseling will need to come from a medical model. Curtis insists that isn’t the case. “Counselors can work within the medical model without working from the medical model,” he says. “Counselors can serve as change agents within medical practices to bring even more of a humanistic perspective.”

Shrinking violets need not apply

When Travis interviews counseling and psychology students to intern at the medical center, he tells them it’s a two-way street — they’re evaluating him and the environment as much as he is evaluating them. He reminds them they would be working in a physician’s office, which features an entirely different environment and energy than traditional counseling settings.

In integrated care settings, counselors must adapt to the way that physicians talk, which is chock-full of acronyms, Travis says. They will also need to get comfortable and remain confident in an intense and energetic environment, even if some physicians fail to give counseling the respect it deserves. “This is not always the most validating environment for emotional things,” Travis says. Some doctors may be outspoken in insisting that they don’t “do that touchy-feely stuff,” he says, implying that they believe the work that counselors or other behavioral health professionals do is somehow beneath that of doctors.

Regardless, Travis’ hope is always that his counseling graduate students will mesh with the environment and go on to find full-time work within integrated care settings. More than a decade ago, one of the first graduate students with whom Travis worked went on to start a private practice with two of the medical residents she had interned with.

Still, Travis admits that integrated care settings aren’t going to be a fit for every counselor. Counselors who possess a strong degree of self-confidence and wouldn’t be easily intimidated by physicians are most likely to thrive in integrated care environments, he says. Integrated care also requires clinicians to get comfortable doing counseling in nontraditional settings such as medical exam rooms, he adds.

Curtis says counselors in integrated care settings can’t be shrinking violets. “You have to have confidence, knowing and believing that you provide a very valuable service and that research suggests your counseling is causing changes within the body and brain equal to what a tablet [of medicine] would do,” he says.

Counselors working in integrated care must also be ready and willing to make other adjustments. In this fast-paced environment, behavioral or mental health clinicians won’t typically have the ability to book eight clients a day for 50-minute sessions each, especially if the clinician is the only one on staff, Curtis says. “If you’re coming from a counseling program where you doggedly stick to the 50-minute session and think that’s the right way to do it, that’s not going to be effective in some integrated care settings,” he says.

Counselors desiring to work in integrated care must also boost their knowledge of medications, Curtis says. He emphasizes that this isn’t limited to psychiatric medications. Counselors also need to know about many of the drugs prescribed for heart disease, diabetes and other common ailments, he says. That’s because physicians may rely on counselors to help determine whether a patient’s symptoms are side effects of the medications they are taking or possible indications of a mental health issue.

It is also helpful for counselors to be aware of the services available in the surrounding community, Curtis says, so they can connect patients with the support they need, from crisis management to housing.

Another aspect of integrated care that can take some adjustment is navigating confidentiality with patients. This needs to be addressed early in the informed consent process by making patients aware that their information will be accessible to both the medical and counseling staff, Curtis says. “Tell patients you’re working as a team. Tell patients, ‘We’ll keep the notes strictly to how to best help with your treatment, and if there’s something you don’t want me to share, be specific about it.’”

It is not uncommon for doctors and nurses to discuss patients in the hallway, Curtis says, but when it comes to counselors and doctors discussing a patient’s progress, that can raise a red flag. Curtis says counselors must set clear boundaries when it comes to confidentiality. They need to have the confidence to say to a doctor, “You know, I don’t feel comfortable discussing this here. Let’s go into this office so we can talk about it privately.”

Curtis suggests that counselors who think integrated care might be a good fit for them apply a grass-roots approach to find work. He advises counselors to reach out to their contacts in the medical field, explain the idea of integrated care and ask if they are interested in pursuing it. Curtis uses the same approach to find integrated care internship sites for his students. He says that over time and with some persistence, progress can be made and opportunities will present themselves.

Healing approaches

Each summer, Curtis teaches an online course about integrated care called “Positive Psychotherapy in Integrated Care.” He says the focus on positive psychotherapy is based on the idea that to truly improve one’s health and to heal, people must reenvision their lives. “Medicine can ‘cure,’ but unless people are healing for new and higher purposes in their lives, they’ll just get sick again,” Curtis says. “And although that’s pretty ‘woo-woo’ stuff, the positive psychotherapy interventions of mindfulness, gratitude, forgiveness [and] using personal strengths have been shown to improve mood, health and cognitive functioning.”

Positive psychotherapy interventions such as the ones Curtis mentions are also relatively easy for patients and clients to practice on their own, he says. In a fast-paced integrated care setting in which counselors may not have the luxury of spending 50 minutes with each client, those interventions can be particularly helpful. Counselors can give clients some sort of positive psychotherapy “homework,” such as practicing gratitude, to reinforce the treatment.

Curtis says the foundation for working with clients in an integrated care setting is the same as in any other setting: Get to know the client, and listen well. “That’s your base,” he says. “Then from there, I think both solution-focused and cognitive behavior therapy (CBT) are [good] ways to go.”

Solution-focused approaches guide clients to think about times in their lives when they weren’t feeling bad and then determine what they were doing differently at those times, Curtis says. CBT approaches help clients consider how their thoughts may be making the matter at hand worse, whether that is a physical issue or something else, he says.

Travis adds brief therapy, stress management, relaxation, family systems work and chemical dependency treatments to the list of counseling approaches that can be particularly helpful in integrated care settings, while Jacobson mentions strengths-based and wellness-based approaches, motivational interviewing and evidence-based brief interventions.

Integrated care without integrated insurance

Christian identifies billing and receiving payment as one of the biggest challenges for counselors in integrated care settings. The root of the problem, he says, is that we have yet to experience the impact of what was called for in the Mental Health Parity Act, which should end differentiation between the insurance benefits allowed under physical and behavioral health plan structures. The current reality is that some patients have medical health insurance but limited or no behavioral health coverage. Other patients may have behavioral health coverage, but their deductible is separate from their medical coverage and much higher. 

When linking behavioral health providers to an integrated care setting and ensuring they can bill for their services, Christian says the key is matching the therapist with the type of setting as much as possible. “An example would be that an LPC [licensed professional counselor] would not be ideal for billing scenarios in a medical clinic that had a significant number of Medicare patients for whom the LPC cannot bill,” Christian says. “Specialty clinics such as cardiology would be an example [of that], but some internists have significant numbers of older patients [as well]. Conversely, in pediatric clinics, LPCs do not run into the need to bill for Medicare.” So, Christian says, the best match in some cases may be linking an LPC with a pediatric clinic.

It’s also important for a counselor to be on as many insurance panels as possible so they can service the widest array of patients in-network, Christian says.

Jacobson sees counselors’ lack of recognition by Medicare as a hurdle that must be overcome for the good of counselors’ potential clients. “As the baby boomers age, they need professional counselors too,” she says. “In many instances, those [who are] 65-plus only see their primary care physician. Sometimes physicians consider depression … a ‘natural’ part of aging. Just because aging is a natural progression doesn’t mean depression is. There is an increased risk of suicide among the elderly due to depression from pain, isolation, neglect, abuse and limitations. Counselors are needed to help in settings where the elderly are to provide the extra human touch and to connect in a very real way.”

Some states have opened up health behavior assessment and intervention (HBAI) codes, Christian says, allowing therapists in integrated care settings to work under physicians with certain patients. “HBAI codes are used when a patient with a physical health diagnosis would benefit from interaction with the in-house therapist to assist with behavioral approaches to better manage their complex chronic condition,” Christian explains. “For example, a patient who has a complex medical regime could benefit from spending time working on [coordinating] their self-management techniques to become more successful in coping with their condition. Another patient who just learned of a life-changing physical health diagnosis could benefit from a discussion with the behavioral health provider, which could include a check-in at some point later. [Otherwise] these patients would not likely seek out traditional [therapy] until they had struggled. They could by then be depressed and/or very anxious.”

Travis notes that insurance doesn’t affect his center’s counseling and psychology graduate students because they are working as interns for credit rather than for reimbursement. He forecasts, however, that the challenge ahead will be moving to an integrated payer system instead of fee-for-service.

For his part, Christian is hopeful that billing and payment for integrated care will get increasingly streamlined as insurance companies become more aware of comorbidities and the effectiveness of treating the mind alongside the body.

The right fit

Having counselors in integrated care settings doesn’t negate the value of counselors who don’t work in integrated care settings. After all, Travis says, the need for specialty mental health will always exist. “As much as I espouse integrated care, it is not the end-all-be-all,” he says. “[It] cannot address all the aspects of care that some severe mental illness requires.”

Ideally, integrated care should represent one service point along the entire range of an optimally functioning service delivery system, Christian says. “Patients with mild to moderate needs can be seen in primary care settings, and the behavioral health provider can act as a liaison to the greater behavioral health community for patients with more intensive needs,” he says.

Jacobson adds that specialists may even be needed in integrated care settings in some cases, such as a play therapist working within a pediatric office or a trauma specialist working within a hospital. The bottom line, she says, is that there is enough room and enough need for everyone — but unless counseling as a whole takes action to move forward into new areas such as integrated care, it risks being left behind.

While still a graduate student, Jacobson attended a conference last year about integrated care and the push for it in Kentucky. “Hundreds of physicians, psychologists, social workers, nurse practitioners and psychiatric nurses were there,” she recalls. “Not once did the conversation from the panel mention counselors. Not one LPCC (licensed professional clinical counselor) was seen on the list of attendees. After the panel dispersed, I approached Benjamin Miller,” a clinical psychologist and director of the Office of Integrated Healthcare Research and Policy at the University of Colorado Anschutz Medical Campus. “I asked why counselors weren’t at the table, and he said, ‘Don’t worry about the why. The bottom line is there’s plenty of room for everyone.’ It truly motivated me to advocate even more. Right now, there’s room for us. Let’s break down the barriers and pull up our sleeves.”

The alternative isn’t a good one, Jacobson warns. “In addition to the competition we’ll face, those interested in learning the [integrated care] approach will need to learn it from other professions if we don’t teach it and adapt it to our standards.”

Besides, Jacobson says, counseling’s core values and approach would seem to be the perfect match for integrated care. “It is only natural for counselors to work holistically with our clients,” she says. “In fact, we’re getting back to our wellness roots.”

Travis agrees. “The counselor’s view is grounded in development, growth and life transitions, which fits a lot of the health issues addressed by family physicians,” he says. “Many primary care issues can be viewed as development[al] or adjustments to life phases and stress related. Taking a strengths-based, wellness approach can create positive impact and motivation and drive understanding for the patients or clients that they have power over their health.”

Beyond being a good fit for counselors, Jacobson maintains that integrated care offers the greatest promise for delivering optimal service to the people who matter most: clients. “For many people, the reduced stigma [of receiving counseling] in a holistic, integrated care setting could prove to be the long-awaited answer. Not only is there a promise of improved clinical outcomes but also a chance to prevent potentially disabling conditions. Let’s face it, integrated care just makes sense.”

Integration education

Looking for more information on integrated care and steps to take toward working in an integrated setting? Here are a few places to start — many suggested by the individuals interviewed for this article.

• ACA Integrated Care Counseling Interest Network (to join, email Holly Clubb at hclubb@counseling.org with your name, email address and name of the interest network)
• ACA podcast on “Integrated Care: Applying Theory to Practice” with Russ Curtis and Eric Christian (counseling.org/knowledge-center/podcasts)
• Integrated Care: Applying Theory to Practice by Russ Curtis and Eric Christian, published by Routledge
• Integrated Care in Action (DVD) edited by Russ Curtis and Eric Christian, published by Routledge (this DVD is included when Curtis and Christian’s book is purchased but is also available for purchase separately at routledge.com)
• SAMHSA-HRSA Center for Integrated Health Solutions (integration.samhsa.gov)
• University of Massachusetts Medical School Center for Integrated Primary Care (umassmed.edu/cipc/index.aspx)
• National Council for Behavioral Health (thenationalcouncil.org)
• The Academy for Integrating Behavioral Health and Primary Care (integrationacademy.ahrq.gov)
• North Carolina Foundation for Advanced Health Programs (ncfahp.org/integrated-care.aspx)
• Collaborative Family Healthcare Association (cfha.net)
• Integrated Behavioral Health Project (ibhp.org)
• “Positive Psychotherapy in Integrated Care,” an online course offered through Western Carolina University (email Russ Curtis at curtis@wcu.edu)

To contact the individuals interviewed for this article, email:

• Eric Christian at echristian@ccwnc.org
• Russ Curtis at curtis@wcu.edu
• Teresa Jacobson at teresajacobson@awakenyourdestiny.org
• Craig Travis at ctravis3@ohiohealth.com 

Lynne Shallcross recently left her position as associate editor and senior writer for Counseling Today to pursue a graduate degree in journalism at the University of California, Berkeley. Making that decision was not easy, and she sends her sincere gratitude to each and every reader of Counseling Today, saying she considered it a true honor and privilege to write for you over the past four-plus years. Lynne can still be contacted at lshallcross@counseling.org.

Letters to the editor: ct@counseling.org