Internship in Integrated Health
Care Practices: Opportunities for
Counselors
Russ Curtis, PhD, LPC and Mehgan McNeil, M.S., LPCA
Western Carolina University
curtis@wcu.edu
2.22.13
Table of Contents
1.
2.
3.
4.
5.
6.
Integrated Care Defined
Need for Integrated Care
Supporting Research
Training Integrated Care Professionals
Internship in Integrated Care
Resources
Date
Medical Procedure
Cost (2004)
12-24-04
ER visit
$1,178.37
Labs
$150.00
Medical imaging
$35.00
1-3-05
Follow up labs
$133.00
1-7-05
Stress test
$423.34
1-10-05
Pulmonary
specialist
$150.00
2-05
2nd Stress test
$423.00
2-05
EEG #1 (approx.)
$450.00
3-05
EEG #2 (approx.)
$450.00
9-05
Trip to ER
$1000.00
Total
$4,392.71
Cost (2013)
$6,143.68
Return on Investment of CBT for
Anxiety
CBT for Adult
Anxiety
Total Benefits
Costs
Net Benefit
Odds of net
present value
$17,731
$341
$17,390
97%
Lee et al. (2012)
http://www.wsipp.wa.gov/pub.asp?doc
id=12-04-1201
What IC can do
• Further humanizes the medical culture
• Reaches people who would otherwise never
seek counseling
• Gets closer to prevention
• Quality relationships are good for our physical
health
My Experience with IC
• MD: 60% of day was spent dealing with MH
and SA issues
• Mental health, psychiatrist, and pneumonia
• WCU student and Dr. Nicholas Cummings
• Psychiatrist asking me to check hospitalized
client
1. Integrated
Care Defined
“Integrated care is the seamless and dynamic interaction
of PCPs and BHPs working within one agency providing
both counseling and traditional
medical care services.” Curtis & Christian, 2012
Models of Integrated Care
• Non-Targeted/Horizontal Integration
• Provides a broad array of services to clients with
various health related needs and concerns –
Population focused
• Examples: family medical practices, public health
centers, Federally Qualified Health Centers (FQHC)
Models continued
• Targeted/Vertical Integration
– Provides treatment for high risk clientele with
specific concerns (i.e., diabetes, substance abusing
pregnant women, cancer patients, & metabolic
syndrome)
– Example: Cancer Patient Support Program, Wake
Forest University Medical Center
Models cont.
• Reverse Integration
– Physical health physician working within mental
health agencies to address the unmet physical
heath needs of those with significant mental
illness.
– SPMI patients often neglect their physical healthy
issues – ie. Metabolic Syndrome
2. Need for Integrated
Care
“Integrating services is
increasingly
recognized as
important to achieving
both the quality and
cost-savings goals of
health reform.”
Kathleen Sebelius, 21st
Secretary of the Department
of Health and Human Sevices
(in Butnett, CounselingToday,
June 2012)
• Only 40% of clients needing mental health
services are identified by primary care physicians
(PCPs).
• Of the 40%, only 10% seek mental health
treatment.
• A significant percentage of elderly clients who
committed suicide had visited their PCP within
one month prior to their deaths (Conwell, 2001).
Common clinical presentations don’t fit
neatly within medical or MH boxes
• 50% of all MH care is done by PCP’s.
• 67% of all psychoactive drugs prescribed by PCP’s
• Referral to MH/CD hard to navigate; often doesn’t
connect. 50-90% follow-through Escobar et al, 2006
• Depression diminishes outcomes in medical conditions
CJ Peek, PhD
• Up to 70% of primary care visits have a psychological
basis
• Approximately 25% of patients in a primary care
setting have a psychiatric disorder.
• Only 3-5% of the population sees a mental health
professional in any given year
Robert Graham Center, “Why there must be room for mental health in the medical home;
NBGH: An Employers’ Guide to Behavioral Health Services
Frank deGruy (2010). Kentucky
Policy Summit
Common Medical Illnesses
and Depression
Multicondition 23%
Seniors
Major
Depression
30-50% Stroke
15-20% 11-15%
Heart
Disease
Diabetes
Untreated Mental Health =
More Healthcare Use
• Depressed patients use 3 times more healthcare services
• Depressed patients have 7 times more ED visits
• Depression is associated with longer hospital stays
• Only 50% diagnosed accurately in primary care
• Of those started on antidepressant treatment by their
PCP, only 40% recover by 4 to 6 months
– Of those treated, < 1/2 receive recommended care
Untreated MH = lost productivity
• Absenteeism
– Depressed workers miss work 2x as often as nondepressed workers
• “Presenteeism” (reduced productivity while at
work)
– Depressed workers have 7x greater odds of
decreased workplace effectiveness
Druss et al. Am J Psychol, May,
2001
Associations of Mood Disorders with Work
Performance
 Major
Depressive Disorder
− 27.2 lost work days per worker per year
− US civilian labor force yielded 225 million lost work
days (> $36 billion salary-equivalent productivity per
year)
•
Bipolar Disorder
− 65.5 lost work days per worker per year
− US civilian labor force yielded 96.2 million lost work
days (> $14 billion salary-equivalent productivity per
year)
Kessler, Akiskal, Ames, et al. Am J Psychiatry, 2006
Top 10 Health Conditions Driving Full Costs for Employers
(Med + RX + Absenteeism + Presenteeism) Costs/1000 FTEs
$400,000
$350,000
$300,000
$250,000
Presenteeism
Absenteeism
Drug
Medical
$200,000
$150,000
$100,000
$50,000
$0
Loeppke, R., et al., "Health and Productivity as a Business
Strategy: A Multi-Employer Study“. JOEM. 2009;51(4):411428.
Frank deGruy (2010). Kentucky Policy Summit
Number of physical symptoms
Frank deGruy (2010). Kentucky
Policy Summit
3. Research
PC is Preferred Location
• 50-90% of referrals to BHPs
outside of clinic setting did not
result in therapy (Glenn 1987,
Cummings 1990)
• Depressed patients are more
likely (91%) to accept care in
primary care setting, which is
significant when considering
only 50% show up for first
appointment with referral to
an outside office (Katon 1995)
Research: IC
• Improving client and physician satisfaction with care
(Kates, Crustolo, Farrar, & Nikolaou, 2001; Kenkel,
Deleon, Mantel, & Steep, 2005)
• More likely to receive counseling (Kessler, 2012)
• Improving client outcome (Wang et al., 2007)
• Reducing over health care costs (Katon et al., 2002).
Adolescent Depression
• Depressed adolescents in IC reported
significantly less depressive symptoms,
increased quality of life and were more
satisfied with the care they received at the 6
month follow up compared to a treatment as
usual group (Asarnow et al., 2005).
Behavioral Issues
• Children (5-12 years old) with behavioral
problems demonstrated significant
improvement among those treated in an
integrated care practice compared to
treatment as usual (Kolko, Campo, Kilbourne, &
Kelleher, 2012).
Decrease in Depression
over time
Month 1
Month 2
Month 3
Month 4
Month 5
Month 6
Month 7
Month 8
Months of Service
45
40
Increase in Mental
Functioning over
Time
35
30
25
20
15
10
5
0
Before
Services
Month 1
Month 2
Month 3
Month 4
Month 5
Month 6
Month 7
Month 8
Months of Service
80
Fewer missed work days
in Past 3 Months Due to
Emotional Reasons
70
60
Percentage
20
18
16
14
12
10
8
6
4
2
0
Before
Services
Average Score
Average Score
Buncombe County Health Center Integrated Care Project
50
40
30
20
10
0
Before Services
Months 1-2
Months 3-4
Months of Service
Months 5-6
Months 7+
4. Training Integrated
Care Professionals
Training students IC Internship
• Training Manual for Behavioral Health Interns
•
•
•
•
•
•
Community Mental Health Contacts
Electronic Medical Record (EMR)
DSM-IV Criteria for most common mental health diagnosis
Common Psychiatric medications rx’d by physicians
Evidence-based therapeutic techniques
Assessment instruments
• Shadowing Behavioral Health Providers,
Psychiatrist and Residents
• Consultation, Intake, Psychotherapy sessions
IC Core Competencies
Strosahl (2005)
1.
2.
3.
4.
5.
6.
Clinical Skills
Practice Management Skills
Consultation Skills
Documentation Skills
Team Performance Skills
Administrative Skills
5. Internship in Integrated
Care
Typical IC Internship duties
•
•
•
•
•
•
•
•
Conducting Clinical Evaluations
Assessments
Conduct Individual Psychotherapy Sessions
Consult with Physicians and Residents
Complete Case Notes Using EMR
Provide Behavioral Health Consultations
Case Management
Attend BH Didactics
Snapshot: An Integrated Care Program
Nurse screens clients to
establish care and annual
appointments
Physician sees client
and validates screening
Physician introduces
client and counselor
Physician and counselor
provide team approach
for coordinated care
Behavioral Health Services integrated
with Primary Health Care:
• Screening
• Assessment
• Brief supportive counseling
• Therapy
• Case management
• Medication monitoring
• Coordinated team care
PHQ -9
Depression Protocol
1.
2.
3.
4.
5.
Medication Management
PHQ-9
Self Care Action Plan
Counseling?
Appointment reminder
Integrated Care for Depressed
Patients
Barrett & Landis, 2012
3 groups of patients: No consulting or CM (grp N);
Consulting services but no CM (grp C); full IPC
(consulting and CM-grp IPC)
Grp N: 9/1/04 - 5/31/05 N=169 with PHQ9 of 10 or
more
Grp C: 1/1/09 - 10/8/09 N=350
Grp IPC: 1/1/10 - 2/5/10 N=33
Three Measures of PHQ9 Improvement, by Group (Barrett &
Landis, 2012)
Establishing IC Internship
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•
•
•
•
•
•
LPCA billing, “Incident to the physician”
Hospitals (possibly chaplaincy department)
Pediatrics
Federally Qualified Heath Centers (FQHC)
University health centers
Veteran Affairs
Persistent and consistent
6. Resources
Positive Psychotherapy in Integrated
Care Class
“It has often been pointed out that in healthcare
it is 20 years after the proven effectiveness of
a treatment before it is fully adopted. In this
point of view, it will be 10 more years before
integrated care is mainstream.”
Cummings, O’Donohue, & Cummings, 2009
Resources
Podcast, Video and Books:
• Curtis, R., & Christian, E. (American Counseling Association). (2012, August). Integrated
Care: Applying theory to practice [Audio podcast]. Retrieved from
http://www.counseling.org/Counselors/TP/PodcastsHome/CT2.aspx
• Curtis, R., & Christian, E. (Routledge). Integrated Care in Action [DVD]. Available from
http://www.routledge.com/books/details/9780415891325/ also available from Alexander
Street Press
http://www.emicrotraining.com/product_info.php?cPath=22_82_116&products_id=539
• Blount, A. (Ed.). (1998). Integrated primary care. The future of medical and mental health
collaboration. New York, NY: W. W. Norton.
• Curtis R., & Christian, E. (Eds.). (2012). Integrated Care: Applying Theory to Practice. New
York: Routledge.
• O’Donohue, W. T., Byrd, M. R., Cummings, N. A., & Henderson, D. A. (Eds.). (2004). Behavioral
integrative care. Treatments that work in the primary care setting. New York, NY: BrunnerRoutledge.
• Patterson, J., Peek, C. J., Heinrich, R. L., Bischoff, R. J., & Scherger, J. (2002). Mental health
professionals in medical settings. New York, NY: W. W. Norton & Company, Inc.
• Robinson, P. J., & Reiter, J. T. (2006). Behavioral consultation and primary care: A guide to
integrating services. New York, NY: Springer.
Selected References
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Aitken, J.B., & Curtis, R. (2004). Integrated health care: Improving client care while providing opportunities for mental health
counselors. Journal of Mental Health Counseling, 26, 321-331.
Conwell, Y. (2001). Suicide in later life: A review and recommendations for prevention. Suicide and Life Threatening Behavior,
31(Suppl), 32-47.
Doherty, W. J., McDaniel, S. H., & Baird, M. A. (October, 1996). Five levels of primary care/behavioral healthcare
collaboration. Behavioral Healthcare Tomorrow, 5(5) 25-28.
Escobar, J. I., Gara, M. A., Diaz-Martinez, A. M., Interian, A., Warman, M., Allen, L. A., Woolfolk, R. L., Jahn, E., & Rodgers, D.
(2007). Effectiveness of a time-limited cognitive behavior therapy-type intervention among primary care patients with
medically unexplained symptoms. Annals of Family Medicine, 5(4), 328-335.
Frank, R. G., McDaniel, S. H., Bray, J. H., & Heldring, M. (Eds.). (2004). Primary care psychology. Washington, DC: American
Psychological Association.
Kates, N., Crustolo, A., Farrar, S., & Nikolaou, L. (2001). Integrating mental health services into primary care: Lessons learnt.
Families, Systems & Health, 19(1), 5-12.
Katon, W., Russo, J., Von Korff, M., Lin, E., Simon, G., Bush, T., Ludman, E., & Walker, E. (2002). Long-term effects of a
collaborative care intervention in persistently depressed primary care patients. Journal of General Internal Medicine, 17(10),
741-748.
Mauer B. (2006). Behavioral health/primary care integration: the four quadrant model and evidence- based practices.
Rockville, MD: National Council for Community Behavioral Healthcare.
Mims, S., & Vinson, N. (2007, November). Dollars and sense: One community’s experience with integrated care services and
costs data. Paper presented at the annual meeting of the Collaborative Family Healthcare Association, Asheville, NC.
Rasmussen, N. H., Furst, J. W., Swenson-Dravis, D. M., Agerter, D. C., Smith, A. J., Baird, M. A., & Cha, S. S. (2006). Innovative
reflecting interview: Effect on high-utilizing patients with medically unexplained symptoms. Disease Management, 9(6), 349359.
Wang, P. S., Simon, G. E., Avorn, J., Azocar, F., Ludman, E. J., McCulloch, J., Petukhova, M. Z., & Kessler, R. C. (2007).
Telephone screening, outreach, and care management for depressed workers and impact on clinical and work productivity
outcomes. JAMA, 298(12), 1401-1411.