Integrated interventions

W hen people think about integrated care, they may imagine a mental health care professional (or two) working in the same building with a physician or other medical professional and following a mutual agreement to refer cases to one another as needed. Others might picture a specialized setting, such as a pain clinic or cancer treatment center, where mental and emotional health concerns are addressed in relation to the medical or physical issue. However, multidisciplinary integrated care teams can now be found in hospitals, outpatient medical centers and community mental health clinics. Professional counselors who operate in these settings say that working in concert with other medical, mental and physical health professionals is the best way to provide clients with whole-person care.

Integrated care facilities are often in medical settings such as primary care clinics, but this doesn’t have to be the rule. Sherry Shamblin is chief of behavioral health operations for Hopewell Health Centers, a group of nonprofit community primary care and behavioral health clinics with 16 locations in southeast Ohio. She helped to develop a system that features primary care facilities in which counselors can conduct brief behavioral interventions and centers that focus principally on mental health but also offer primary care resources.

Shamblin’s thinking is that clients who already are struggling to manage serious mental health issues are often too overwhelmed to seek medical care. “If you’re depressed, you don’t really take care of yourself,” says Shamblin, a licensed professional clinical counselor with supervision designation. “You’re not valuing self-care and taking care of your [physical] health.” In addition, many psychotropic medications have side effects such as weight gain, which can increase clients’ chances of developing diabetes and other chronic illnesses, she notes.

“When you physically feel better, your mood improves, your energy is better, [you] feel more like tackling things that seem overwhelming and your overall coping improves,” says Shamblin, a member of the American Counseling Association. “Although mental and physical [health] have been separated for a long time … [the division] is artificial. It’s all connected.”

Counselors at the mental health clinics ask clients at intake whether they have a primary care physician and, if so, who that person is and when the last time was that the client saw their physician. Counselors will also try to get clients’ permission to access their medical records. That way, counselors can work with clients’ physicians to help ensure that clients are getting the health care they need, Shamblin explains.

If mental health clients don’t have a primary care physician or only go when they are feeling really ill, the counselor talks to them about health and wellness and the importance of receiving regular checkups. “We try to help them view it [regular health care] as another component of staying well,” Shamblin says.

If Hopewell Health Centers’ clients don’t have a primary care physician but would like to start taking better care of their health, they don’t have far to go — the mental health care facilities have exam rooms and primary care providers on-site. Having these resources readily available not only makes it easier for clients to access health care but also allows them to receive it in a setting in which they already feel comfortable, Shamblin says. The counselor (or other mental health professional) and onsite primary care provider then become a team dedicated to maintaining the client’s physical and mental health.

In Hopewell Health’s primary care clinics, counselors (who are called behavioral health consultants, or BHCs) play several roles. In some cases, the BHC is brought in to help the client manage a chronic illness. For example, Shamblin says, a primary care physician might see someone whose diabetes or high blood pressure is not under control despite treatment. This would provide an opportunity for the physician or nurse to explain that they have a colleague on the team who might be able to help the patient with this struggle. They would then ask if the patient would like to meet with the BHC.

The BHC would then try to determine the factors that are keeping the patient from progressing. For instance, is the person not taking medicine consistently or not watching their diet? If treatment adherence is a problem, the BHC assesses whether patients are ready to change their behavior and, if so, works with them to set goals and offers ongoing support. If patients are not open to making a change in a particular lifestyle area — such as diet, for example — the BHC would work with them to identify another positive lifestyle change they could make, such as stopping smoking or getting more exercise, Shamblin explains.

In other cases, the BHCs working in the primary care clinics conduct brief interventions with patients. The primary care physicians screen patients by asking questions that assess for signs of depression or substance abuse. If the physicians get an answer that concerns them — perhaps a patient saying that they have been feeling overwhelmed or depressed, for example — they ask the patient whether they can bring in someone who might be helpful, Shamblin says. The BHC will then ask brief questions to help determine whether the patient needs intervention.

Sometimes patients feel better just being given the opportunity to have a short conversation about their worries, Shamblin says. In such cases, the BHC will ask if it is OK to check in with the patient the next time the person returns to the clinic. In some cases, the BHC will ask the patient to come back for a few brief counseling sessions. In other instances, the BHC determines that patients need more intensive mental health care and will refer them to the clinic’s mental health professionals who oversee long-term care, Shamblin explains. The BHC then becomes the liaison between the primary care and mental health providers and will check in with the patient periodically to see how the person is doing, she says.

Hopewell Health Centers was created in 2013 when two organizations, Family Healthcare Inc. and Tri-County Mental Health and Counseling Services Inc., merged in order to provide integrated care. Shamblin notes that the frequency of Hopewell Health Centers’ screenings and treatment of substance abuse has gone up with the introduction of the integrated care model. Some data have suggested that the area of Ohio where the clinics operate has the lowest depression rates in the state, she says.

Leading the way in integration

Wake Forest Baptist Medical Center in Winston-Salem, North Carolina, is a leader in hospital and outpatient integrated care. Just ask ACA member Laura Veach, who explains that the Wake Forest system has moved beyond the concept of integrated medicine being simply “co-located” care. In fact, the system is so integrated that Veach, a counselor educator, is a full professor in the Department of Surgery in the Wake Forest School of Medicine, a position that Veach thinks may be unique. Veach is also the director of counselor training at Wake Forest Baptist Medical Center. Though affiliated with Wake Forest University, the center also works with other counselor educator programs.

Veach has played a crucial role in the medical center’s emphasis on integrated care. She says she feels particularly fortunate because she works with a group of surgeons “who get it and want the best for patients.”

“We [counselors] are embedded in the medical team,” Veach explains. “We started in surgery in the specialty of trauma surgery and began to test the feasibility of doing counseling and screening and intervention at the bedside and [then] became a training site. Now we include posttraumatic stress disorder [PTSD] intervention work, crisis intervention and grief and loss work with trauma patients who have suffered the loss of a loved one in a trauma incident that brought them to the hospital. That led to the pediatric trauma unit, where we work with families of children who are traumatically injured, as well as the children themselves.”

Counselors are also part of integrated care efforts in the facility’s burn center, which is one of the only certified burn centers in North Carolina. Those efforts include providing ongoing counseling sessions in the burn intensive care unit and the step-down unit. Wake Forest Baptist Medical Center has also expanded integrated care into medical inpatient units, where people come in for issues such as pancreatitis, infections, pneumonia and so on.

Wake Forest Baptist Medical Center has a system that scans medical records to help identify patients who might need counseling help. For instance, when patients come through the emergency room, nurses ask them about depression, anxiety, suicidal thinking or past suicidal behavior. Other patients may receive bloodwork that shows elevated blood alcohol content or urine drug screens. Veach emphasizes that these are not for legal use but to help the medical center provide better integrated care. Some people may have elevated liver enzymes, which can be a sign of alcohol abuse, she continues. The medical records also include the physician’s account of what the patient’s complaint is. The chart-scanning system analyzes all of this information to help identify and prioritize who the counselors and other mental health professionals on staff should see first, she says.

Counselors introduce themselves as part of the team to patients and let them know that they are there to support the patients’ recovery and health. They then ask if the patients are open to the counselor spending some time with them. The counselors are rarely turned away, according to Veach.

After reviewing informed consent and confidentiality policies with each patient, the counselors simply listen, Veach emphasizes. “We try to just be present with them, to not ask questions, to hear what they are struggling with,” she says.

Veach notes that most of the medical center’s patients have never been to see a counselor before. So the counselors and counseling graduate students who work on the integrated teams at Wake Forest Baptist Medical Center are essentially educating these individuals about what counseling can provide. They tell patients they are prepared to listen to whatever the patients most want to talk about or need help with.

“What we find most often is that people have a lot to share,” Veach says. “We’re not someone who’s coming to do something to them; we’re someone who is coming to be with them. They might say, ‘I really want to talk to my family about this, but they’ll worry.’ A counselor or addictions specialist can be there and not be judgmental.”

In the medical center’s trauma and burn units, counselors stay on the alert for signs of acute stress or PTSD in patients, Veach says. After being released from the medical center, patients return for medical follow-up visits for the next six months, and counselors continue to check in and evaluate their recovery during this time. In certain cases, the counselors set up extended mental health therapy sessions with patients (scheduled adjacent to their medical visits) or recommend that they see a trauma specialist, such as someone trained in administering eye movement desensitization and reprocessing therapy.

When Veach first started working in integrated care, it was common for surgeons to state that they didn’t need or want to know about patients’ emotional issues — they just needed to know how to repair individuals surgically. “In the past decade, we’ve seen a big shift to asking how do we more fully treat this person to help them have a better chance of healing and without experiencing more trauma,” Veach says. “I think more trauma surgeons [today] know that if we don’t address [these emotional issues] now, we’re going to see them here again.”

Many people undergoing medical treatment aren’t aware of the types of issues that counseling or addictions treatment can help them address, or they don’t know how to access those services themselves, so having counselors as part of the team at Wake Forest Baptist Medical Center is particularly valuable, Veach says. Counselors on staff can make recommendations and point patients toward other resources. For instance, Veach says, families may have been struggling for years to get a loved one into treatment for substance use; counselors on staff at the medical center can offer information on which addictions centers in the area offer family support.

In the trauma and intensive care units, the teams offer dedicated support time for families two days per week. Counselors are on hand during these times to offer snacks and encouragement, Veach says. The integration of mental health into the hospital also extends to support groups, including a weekly trauma survivors’ network, a family member support group and a peer-led burn survivors group, she adds.

Veach has been helping to implement brief intervention counseling services at Wake Forest Baptist Medical Center for a decade. As counseling services have expanded to be included in more and more of the center’s departments, she has been surprised at how receptive medical patients are to counseling. She says she has witnessed “a deeply heartfelt responsiveness” on the part of patients to being heard and understood. In addition, surgeons have begun to tell Veach how valuable counselors are to the team. They tell her they are heartened to see patients getting care from counselors that they, as surgeons, can’t provide themselves.

Putting people first

Marcia Huston McCall, a national certified counselor and doctoral student in counseling and counselor education at the University of North Carolina at Greensboro (UNCG), spent several decades in health care management before becoming a counselor. She worked in the finance department at Massachusetts General Hospital and then became the business director of several different departments in an academic medical center in Winston-Salem, North Carolina.

McCall, an ACA member, says she went into health care management as a means of helping patients. She thought her business acumen was her strongest skill set and her best way of contributing. Over time, however, she became convinced that the business side of health care was moving farther and farther away from helping patients. “Health care management got so corporate,” she says. “I felt separated from the patients, and I wanted to have that contact.”

McCall realized that the people part of her job was what she loved best and decided that a career shift into counseling would be a better fit. She entered the counselor education program at Wake Forest University and completed her practicum and internship hours in inpatient integrated care at Wake Forest Baptist Medical Center. UNCG also has a relationship with Wake Forest Baptist Medical Center, so McCall completed her doctoral internship there and continues to work at the center as a graduate assistant.

McCall has worked in both the outpatient clinic and the inpatient section of the medical center. She says it is crucial for counselors to be full members of the team by participating in rounds and team huddles. “Having the counselor as part of the team when all the patients are being discussed is really important because you’re not only offering perspective but also picking up on things that might be issues,” she says. “They’re talking about patients you might not see [in the outpatient clinic], but you can pick up on patients that you do need to see.”

“In inpatient, we screen patients ourselves, so we review all the new admissions to our floors and identify the patients we think [will] need our services,” says McCall, a member of ACA. If she notices a history of substance abuse or other mental health issues, McCall brings this up before rounds or in the team huddle.

McCall and the other mental health professionals at the medical center conduct brief assessments with patients for signs of substance abuse, depression, anxiety, suicidality and delusions. In some cases, they conduct brief treatment and perhaps even see the patient a few times, depending on the length of stay. McCall also refers patients for further psychiatric or substance abuse care if needed.

Counselors working in integrated care settings frequently need to use their skills to build rapport with patients. For example, a physician might see signs indicating that a patient has possible substance abuse issues and call a counselor in for an assessment. In many cases, patients will not have sought treatment for substance abuse previously and may have avoided acknowledging that they have a problem.

“We’re walking in, and they may not be very interested in talking about their substance issues, particularly with a stranger,” McCall says. “We have to approach resistant patients in an indirect way and try to understand what their issues are and what they want to do about them,” she explains.

In such instances, McCall says that she rolls with the resistance. Friends and family members have likely been asking these individuals to seek help, but the patients haven’t been ready to acknowledge that they need treatment. McCall validates their resistance by verbalizing the arguments they are making against getting help. She says these patients often respond to her validation by saying, “Yeah, but I really do need help.” She then asks them what they are willing to do to get that care. If these patients voice a desire to pursue substance abuse treatment, counselors at the medical center connect them with specialty resources outside of the inpatient or clinic setting.

“We help them find that treatment and do as much as possible to ensure they actually get there — that everything is set up,” McCall says.

Counselors serve as consultants for the medical team at Wake Forest Baptist Medical Center but also act as advocates for the patients, McCall says. A lot of bias still exists among medical personnel about mental health issues, she explains, so counselors are there to help ensure that patients are seen as human beings who have needs, no matter what they have been through.

Counselors may also get called in when a physician is questioning whether a patient might need psychiatric services. The medical center doesn’t have many psychiatrists on staff, so the physicians are hesitant to call them for a consultation if there is no need for immediate inpatient treatment, McCall explains.

By working in integrated care, McCall says she gets to be a kind of ambassador for the counseling profession. “I have the opportunity to work not just with physicians and nurses, but residents, medical students, pharmacy students and physician assistant students,” she says. “[I] really have the opportunity to interact with people who aren’t used to having counselors as part of the team.”

McCall would like to bring even more of the counseling perspective into integrated care. She contends that “behavioral health” is too narrow of a designation and believes that counselors should define their own roles and use terminology that is more appropriate to the counseling profession. McCall says she wants her team, as well as other medical personnel working in different integrated care settings, to be aware that professional counselors are not just behaviorists but also possess many other skills. For example, McCall envisions counselors having a central role to play in helping patients who have gotten a shocking diagnosis or who are struggling with the inherent vulnerability of being in the hospital.

McCall also cautions counselors entering the field to be aware that supervision in integrated care settings is rarely provided by other counseling professionals. It is vital for counselors to maintain their professional identity while operating within integrated care, she emphasizes, even if that means pursuing additional supervision outside of the integrated care setting. Receiving ongoing supervision when working in integrated care is critical because the work can be intense and overwhelming, McCall says. Peer support and supervision can help counselors deal with stress and avoid burnout, she concludes.

Training students in integrated care

Some counseling students interested in integrated care are adding medical knowledge to their counseling skills. Rachel Levy-Bell, assistant professor of psychiatry and associate program director and director of clinical training in the mental health counseling and behavioral medicine program at Boston University School of Medicine (BUSM), teaches and trains counseling students to work in integrated care. The program at BUSM focuses not just on counseling but also behavioral medicine, so students take integrated care courses, learn about psychopharmacology and human sexuality, and get bedside training in getting to know the patient beyond the disease, says Levy-Bell, a member of ACA. She supervises practicum and internship students working in Boston University-affiliated clinics and other Boston community centers.

As part of practicum, Levy-Bell trains small groups of counseling students to conduct biopsychosocial interviews. Each week, the 10-member group receives a list of patients and their medical issues. As the counseling students visit the patients, they take turns being the lead interviewer. Students ask patients about what brought them to the hospital and deduce whether they fully understand their condition and how their disease affects their lifestyle, relationships and work. They also ask how patients physically manage their disease, how they cope with its demands and whether spirituality or religion plays a role for them. They also assess for substance abuse.

At the end of the interview, Levy-Bell asks the patients how they felt the students performed. Many patients share that they like that the students spent more time with them than the medical personnel typically do and also comment that the students are better at maintaining eye contact with them when talking and listening. Afterward, the group goes back to class to evaluate and discuss the interviews: What went right? What do they need to improve? What did they learn?

Part of the training process is getting counseling students used to working in medical settings and grappling with issues such as how to build therapeutic rapport when the patient has a roommate or when medical equipment is everywhere and beeping noises are constant, Levy-Bell says. Students are also exposed to things that they’ve never seen before. These experiences might make them uncomfortable, but they have to learn to control both their verbal and nonverbal reactions to ensure that they aren’t indicating discomfort, she says. Levy-Bell also focuses on practical aspects such as teaching students not to faint — or, at a minimum, fainting away from the patient. She also teaches students to wear light clothing (hospitals are hot), to stay hydrated, to make sure they eat and to take a break if they feel unsteady — but to always come back.

Sara Bailey, an ACA member who works at Wake Forest Baptist Medical Center as part of her postdoctoral fellowship, says that regardless of whether counselors plan to go into integrated care, working in a behavioral health setting provides excellent training. In integrated care, counselors-in-training get the chance to see how other professionals such as doctors, nurses and other mental health practitioners work and handle challenges, she says. They also quickly become aware that all practitioners encounter individuals with alcohol or substance abuse problems.

“In a perfect world, this would be required,” Bailey says. “You get to hone your reflection and rapport-building skills and have to learn to do your best in a short amount of time.”

 

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

• “The counselor’s role in assessing and treating medical symptoms and diagnoses” by Jori A. Berger-Greenstein
• “Advocating for ‘one-stop shopping’ health care: Q+A with ACA’s Interest Network for Integrated Care” compiled by Bethany Bray
• “Using your integrated behavioral health tool box” by David Engstrom
• “Total health care” by Lynne Shallcross
• “Where brain meets body” by Laurie Meyers

Podcasts (counseling.org/knowledge-center/podcasts)

• “Integrated Care: Applying Theory to Practice” with Russ Curtis & Eric Christian (HT030)

ACA Interest networks (counseling.org/aca-community/aca-groups/interest-networks)

• ACA Interest Network for Integrated Care

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.