Session # C2a
October 5, 2012
Ethical Considerations in
Integrated Care:
Behavioral Health Consultation
and Care Management Models
Anne C. Dobmeyer, Ph.D., ABPP
Psychology Proponent, Patient-Centered Medical Home
DoD Deployment Health Clinical Center
Collaborative Family Healthcare Association 14th Annual Conference
October 4-6, 2012 Austin, Texas U.S.A.
Faculty Disclosure
I have not had any relevant financial relationships
during the past 12 months.
The views expressed herein are those of the author and
do not necessarily represent the official policy or
position of the DoD Deployment Health Clinical
Center, Walter Reed National Military Medical
(WRNMMC), Department of Defense (DoD), or the
United States Government.
Objectives
• Identify common ethical dilemmas in
behavioral health consultation in primary care
• Describe ethical challenges that may be
encountered in care management models
• Analyze professional codes of ethics to assist
with resolving such ethical dilemmas
• Discuss whether current ethical standards
adequately address these common ethical
dilemmas in integrated primary care settings
Learning Assessment
A learning assessment is required for CE credit.
There will be opportunity for
Question & Answer periods during and at the
conclusion of this presentation.
Outline
• Overview: Two models of integration
– Primary care behavioral health (PCBH) model
– Care management (CM) model
• Ethical challenges: Examples and guidance
• Application: Participant discussion of scenario
PCBH Overview
• Behavioral health consultant (BHC) integrated
into primary care (PC)
• Functions as consultant to PC team
– PCP remains “in charge” of overall care plan
– BHC provides recommendations to PCP and patients
• Provides focused assessment and intervention
– 15 to 30 minute appointments
– 1 to 4 appointments
• Sees wide range of BH and medical problems
Strosahl, 1998; Robinson & Reiter, 2007
CM Overview
• Care manager (CM), often a nurse or masters’
level provider, integrated into primary care (PC)
• Enhances continuity of care for discrete problem
area (e.g., depression, obesity)
• Follows patients over time
– Assesses progress/symptom changes
– Identifies and addresses barriers to adherence
– Obtains consultation from BH specialist
– Communicates with PCP, who adjusts care plan
Oxman et al., 2002; Barry & Oxman, 2008
Ethical Question #1:
PCBH
“I’ve never worked in a PCBH model before. But
I’ve provided psychotherapy for years, and
have read one of the books on PCBH. I’m
ready-to-go, right?”
Ethical Domain:
Competence
APA Standard 2 Boundaries of Competence 2.01 (e)
(e) In those emerging areas in which generally recognized standards for
preparatory training do not yet exist, psychologists nevertheless take
reasonable steps to ensure the competence of their work and to
protect clients/patients, students, supervisees, research participants,
organizational clients, and others from harm.
NASW 1.04 Competence
(c) When generally recognized standards do not exist with the respect to
an emerging area of practice, social workers should exercise careful
judgment and take responsible steps (including appropriate education,
research, training, consultation, and supervision) to ensure the
competence of their work and to protect clients from harm.
Ethical Domain:
Competence
• PCBH can be considered an emerging practice
area, without clearly defined professional
guidelines for training and education
• How can one determine appropriate training
and consultation to practice competently in new
area?
– Professional literature
– Position papers/statements from professional
organizations
– Relevant listserv discussions
– Special Interest Group recommendations
Ethical Domain:
Competence
• In the field, growing acceptance that specific
clinical training is needed to develop PCBH skills
• Publications describing training approaches
Strosahl, 2005; Dobmeyer et al., 2003
• Development of established programs
– Internship training
– Externship training
– Certificate programs (e.g., 36 to 80 CE hours)
Ethical Question #2:
PCBH & CM
“Isn’t it an ethical violation to document my
PCBH (or CM) appointments in a shared
electronic medical record? Isn’t this
inappropriate disclosure of confidential patient
information?”
Ethical Domain: Privacy
APA Standard 4.04 Minimizing Intrusions on
Privacy (a): “Psychologists include in written
and oral reports and consultations, only
information germane to the purpose for which
the communication is made”
NASW Standard 2.05 Consultation (c): “When
consulting with colleagues about clients, social
workers should disclose the least amount of
information necessary to achieve the purposes
of the consultation”
Ethical Domain: Privacy
American Nurses Association (ANA) Code of
Ethics Provision 3.2 Confidentiality: “…the
nurse’s responsibility to provide quality care
require that relevant data be shared with those
members of a health care team who have a
need to know.”
“Only information pertinent to a patient’s
treatment and welfare is disclosed”
Ethical Domain:
Informed Consent
APA 3.10 Informed Consent
(a) When psychologists conduct research or provide
assessment, therapy, counseling, or consulting
services in person or via electronic transmission or
other forms of communication, they obtain the
informed consent of the individual or individuals using
language that is reasonably understandable to that
person or persons except when conducting such
activities without consent is mandated by law or
governmental regulation or as otherwise provided in
this Ethics Code.
Informed Consent & Privacy
PCMH Informed Consent Process:
 Mandatory
 Verbal and written formats
 Consistent with primary care setting
 Describes handling of patient information
 Discussions with PCP
 Documentation in medical record
 Other limits of confidentiality
Ethical Question #3: CM
“Our Care Facilitator is a general registered nurse,
not a psychiatric nurse. I’m concerned about
whether its ethical for him to be assessing and
managing suicidal patients in our Care
Management program for depression.”
Ethical Domain:
Competence
ANA Provision 4.3 Responsibility for Nursing Judgment
and Action: “When the needs of the patient are
beyond the qualifications and competence of the nurse,
consultation and collaboration must be sought from
qualified nurses, other health care professionals, or
appropriate sources.”
Ethical Domain:
Competence
• CM program should include risk management protocols
– Designed to be administered by nurse
– Accompanied by training
– Assisted by consultation/supervision
– Supported by immediate referral options
Ethical Question #4: PCBH
Participant Discussion
“I’m concerned that PCBH brief assessment
and intervention (one to four 30-minute
appointments) is unethical because I’m not
meeting standard of care”
“Isn’t this substandard care?”
Ethical Question #4: PCBH
Standard of Care
To meet Specialty BH standards of care for
assessment and treatment, what would
our practice likely entail?
Ethical Question #4: PCBH
Standard of Care
Without the addition of PCBH in primary
care…
To meet primary care standards of care for
assessment and treatment of BH
condition, what would practice likely
entail?
Ethical Question #4: PCBH
Informed Consent
NASW 1.03 Informed Consent
(a) Social workers should provide services to clients only
in the context of a professional relationship based,
when appropriate, on valid informed consent. Social
workers should use clear and understandable
language to inform clients of the purpose of the
services, risks related to the services… reasonable
alternatives, client’s right to refuse or withdraw
consent, and the timeframe covered by the consent…
Ethical Question #4: PCBH
Beneficence & Service
APA Principle A Beneficence: “Psychologists
strive to benefit those with whom they
work and take care to do no harm”
NASW Core Social Work Value Service:
“Social workers’ primary goal is to help
people in need and address social
problems”
References
Barry, S. L., & Oxman, T. E. (2008). Three-component model for
primary care management of depression and PTSD (Military
version): RESPECT-Mil care facilitator reference manual, 3CM,
LLC.
Dobmeyer, A. C., Rowan, A. B., Etherage, J. R., & Wilson, R. J.
(2003). Training psychology interns in primary behavioral
health care. Professional Psychology: Research and Practice,
34, 586-594.
Oxman, T. E., Dietrich, A. J., Williams, J. W. Jr., & Kroenke, K. (2002).
A three-component model for reengineering systems for the
treatment of depression in primary care. Psychosomatics, 43,
441-450.
References
Strosahl, K. D. (1998). Integrating behavioral health and primary
care services: the primary mental health care model. In A.
Blount (Ed.), Integrated primary care: The future of medical
and mental health collaboration (pp. 139-166). New York:
Norton.
Strosahl, K. D. (2005). Training behavioral health and primary care
providers for integrated care: A core competencies approach.
In W. T. O’Donohue, M. R. Byrd, N. A. Cummings, & D. A.
Henderson (Eds.,), Behavioral integrative care: Treatments
that work in primary care settings (pp. 15- 52). New York:
Brunner-Routledge.
Anne C. Dobmeyer, Ph.D., ABPP
Psychology Proponent, Patient-Centered Medical Home
DoD Deployment Health Clinical Center
Defense Centers of Excellence
anne.c.dobmeyer@health.mil
(301) 312-1876
Session Evaluation
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evaluation form to the classroom monitor
before leaving this session.
Thank you!