Exploring Integration of Health and Counseling Centers: Best Practices Task Force

1. Exploring The Integration of Health and Counseling CentersMental Health Section “Best Practices” Task ForceACHA Annual MeetingPhiladelphia, June 2010

2. Program Goals Objective 1: Overview of task force • History of the task force • Current charge of the task force • Membership of the task force

3. Program Goals Objective 2: Discuss issues relevant to merger of centers • Issues related to mergers • Staff concerns of mergers • Rationale for and against merger

4. Program Goals Objective 3: Review of the survey and data collection results Objective 4: Discuss implications of collected quantitative and qualitative data

5. Task Force Members Keith Anderson, PhD (Rensselaer Polytechnic Institute) Sylvia Balderrama, EdD (Vassar College) James Davidson, PhD (University of Nevada, Las Vegas) Peter De Maria, MD (Temple University) Gregory Eells, PhD (Cornell University) Caroline Greenleaf, JD (The Julliard School) Joy Himmel, PsyD, RN-CS, LPC (Penn State University-Altoona) Heidi Levine, PhD (State University of New York-Geneseo) Kevin Readdean, MSEd (Rensselaer Polytechnic Institute) Drayton Vincent, MSW, LCSW (Louisiana State University) Joy Wyatt, PhD (Case Western Reserve University)

6. History of the Task Force • Initially suggested by Joetta Carr, Mental Health Section chair (2004) • Focused on exploring practice guidelines • Gradually began to focus on more specific issues • Based on the geographic constraints of the Task Force, early meetings were held in Philadelphia

7. Task Force Charge • Primary charge is the development of a white paper that discusses the issues that are relevant to the integration of counseling centers and health centers on campuses. • Current trends suggest integration of counseling and health centers continues to be a salient issue among campus administrators. A variety of concerns and issues are present during these mergers. • Where relevant, offer suggestions for resolving these concerns.

8. Secondary Charge • Provide guidance to the Board of Directors regarding strategies to increase dialogue within ACHA and with others about college mental health issues. • Task Force sponsored a summit of the leadership of allied professional associations and groups whose memberships are concerned with college mental health.

9. Through its partner organizations, HEMHA represents over 217,000 individual members. • American College Counseling Association (ACCA) • American College Health Association (ACHA) • American College Personnel Association (ACPA) • American Psychiatric Association (APA) • American Psychological Association (APA) • American Psychiatric Nurses Association (APNA) • Association for University and College Counseling Center Directors (AUCCCD) • The Jed Foundation • National Association of Student Personnel Administrators (NASPA)

10. Integration as a Hot Topic • Recent ACHA Annual Meeting Topics • A Primer for the Integration of Health and Counseling in a University Health Service • Initial Lessons Learned on Integration of Primary Care Services and Counseling Services • Integration of Primary Care and Counseling Services: The New York University Experience • Blending Mental Health and Student Health: One Experience in Integration • Leadership Issues Among Primary Care, Psychiatry, and Counseling: Coordination, Case Management, and Medications

11. Literature Review • An Outcome Survey of Mergers Between University Student Counseling Centers and Student Health Mental Health Services (Federman, Russ, & Emmerling, D: 1997, JCSP) • Merger 1980: The organizational integration of college mental health services (Foster, T: 1982, JACHA) • Integration of behavioral health and primary care services: The Group health cooperative model. (Strosahl, K, et. al: 1997, in Cummings, Cummings and Johnson, Behavioral Health in Primary care)

12. Literature Review cont • Developing an Integrated Primary Care Practice: Strategies, Techniques, and a Case Illustration. (Walker, B., & Collins, C.: March, 2009, JCP) • Integrated Care in College Health: A Case Study. (Tucker, C., Sloan, S. K., Vance, M. & Brownson, C., 2008, JCC) • The need for integrating behavioral care in a college health center. (Alschuler, K., Hoodin, F., & Byrd, M., 2008, Health Psychology)

13. Survey Construction • Development • Content • Implementation • Analysis of data • Qualitative data

14. Development • Communication issues • Confidentiality • Record keeping • Physical facilities • Multi-disciplinary issues • Cultural differences • Reporting structure • Ethics • Accessibility for students • Equitability/staff issues • Strategic planning • Treatment approaches • Staff and credentials • Student impact/reactions • Staff reactions • Internal referrals • External referrals • Peer review • Quality assurance • Benchmarking • Reporting, annual • Staff supervision • Philosophical approaches • Budgeting/fees • Components

15. Content • Clinical supervision • Case conference • Administrative meetings • Productivity • Trainees • Professional development • Research • Outreach/programming • Other resources/interaction with campus • Sexual assault • Substance abuse • Accreditation • Scheduling • Use of IT • Website • Marketing • Support staff • Hours of operation • Ancillary services – dietitian, SA, LD, sports med, athletic trainer • Emergency coverage • Testing • Dismissal of case • Fee for service issues

16. Questions of Interest • How many centers are merged • Different models of integration • Rationale for merger • Problems resulting from merger • Strategies used for dealing with these issues • Effectiveness of the current model • Who is pleased with the merger, who is not

17. Implementation • Surveys were sent in the fall of 2007 to • ACHA members • SHS listserve • NASPA members • AUCCCD • Surveys were completed by staff working at counseling and health centers at schools across the country • When multiple responses occurred, mental health responses were used for the institutional response • 359 useable surveys were returned • Of 359 responses, 92 (25.6%) were from Integrated Centers

18. Defining an Integrated Center • Health services director and counseling services director report to a single center director, the center director reports to a senior administrator (n=29) • Single chief health and counseling director reports to a senior administrator (n=20) • Health services director reports to the counseling services director who reports to a senior administrator (n=16) • Counseling services director reports to the health services director, the health services director reports to a senior administrator (n=27)

19. Size of Integrated Campuses

20. Discipline of Respondents

21. Factors Driving Change to Integration

22. Integration Outcomes • Staff communication • Staff morale • Efficiency of administrative processes • Funding/budget • Ability to meet the needs of clients

23. Integration Outcomes cont • Quality of Clinical Services • Quality of Programs • Comprehensiveness of Services • Comprehensiveness of Programs • Utilization of Services • Client Satisfaction

24. Integration Outcomes cont

25. Percentage Reporting Decline After Integration

26. Counseling and Health Collaboration

27. Centers Reporting Frequent or Extensive Counseling/Health Collaboration

28. Discipline of the Center Director

29. Center Layout: Shared or Separate

30. Separate Charts:What is Duplicated in Records

31. Access to Files:

32. Access to Files: cont

33. Access to Files: cont

34. Psychiatric Services

35. Changes in staff communication

36. Information Sharing

37. Qualitative Interviews • Rationale to conduct qualitative interviews • How schools to be interviewed were selected • Telephone interview process

38. Interview Questions • What factors drove the integration of services? • What issues supported or hindered the integration? • How were decisions made regarding the sharing of patient/client information? • What aspects of the services were improved or diminished? • What were the reactions of students, staff and campus?

39. Interview Responses Findings from schools with “more positive” results: Findings from schools with “less positive” results: Motivation for integration: • Enhancing patient care Process: • Generally positive • Shared philosophy Outcomes: •  patient care •  referral process •  student satisfaction •  staff development •  team focus •  quality assurance Motivation for integration: • Financial concerns or an administrative directive Process: • Resistance from clinicians • Turf issues • Debates over access to records Outcomes: • Similar to the positive comparison schools although the magnitudes were lower

40. Summary • “Merged” counseling and health centers have different meanings at different sites • Administrative structures • Levels of integration of records, services, etc. • How marketed or communicated to the campus

41. Limitations of Study • Small overall sample size • 20% Response rate (359/1800 questionnaires) • Small number of merged centers (N=92) • Smaller schools overrepresented among merged centers • Follow-up Interviews (N=6) • Concerns • How representative of the U.S. • Ability to generalize results • Selection bias

42. Outcomes of Merging • Most sites report improvements in • Communication • Quality of services • Client satisfaction • Utilization of services • Many sites struggle(d) with record sharing • “Merged” doesn’t necessarily mean integrated care

43. Recommendations for Sites Considering Merging 1. A meeting of stakeholders should be convened to discuss the implications of the merger, the logistics of the merger, and the goals 2. Stakeholder input should be sought so that their buy-in will allow for a smoother integration Address the following: A. To what extent will the services be integrated and merged? What will the administrative and clinical care structure look like?

44. Considering Merging cont B. Will the reception areas and reception staff be shared or separate? C. How will consent for treatment and release of information be handled? D. How will clinical records be kept, and who will have access to which parts?

45. Considering Merging cont E. Will there be joint or separate staff meetings and in-service trainings? F. What will be the mission and goals of the new service? G. Will the name reflect a more holistic/wellness approach? H. Will advertising and outreach be integrated or separate? I. How will finances/funding be handled?

46. Future Directions • How clinical outcomes correlate with level of clinical integration and collaboration (multidisciplinary team meetings) • Studies that address the benefits and restrictions of the various models of integration • Exploration of collaborative outreach planning

47. Future Directions cont • Access to records • Benefits • Potential or perceived problems • Student perception • Outcomes

48. Future Directions cont • A step by step guide to integration • Collaborative care models within merged and non-merged centers- how to make it work • Administrative merger vs. clinical merger- outcome differences

49. Exploring The Integration ofHealth and Counseling CentersMental Health Section “Best Practices” Task ForceACHA Annual MeetingPhiladelphia, June 2010