Challenges to Coordinating Care in the age of “Integrated Care”

For those who regularly follow the news on health care the push for “integration” is one of the most frequently highlighted issues.  The Affordable Care Act calls for and mandates greater integration of services.  Moreover, professional organizations and insurance companies have been advocating for greater integration of care for some time. Part of this push for integration is an emphasis on greater communication and sharing of information between treatment providers.  Most clinicians have received communications from insurance companies requesting that we coordinate care with our clients’ physicians.  More recently, professional organizations have been advocating for greater integration of services. The American Psychological Association (and locally, the Illinois Psychological Association) have been very strong proponents of integrating care.  What stands out about the calls for greater integration is the seeming lack of concern about unanticipated negative consequences of such efforts and the emphasis on the value of such efforts. At a recent panel discussion at the November, 2015 Illinois Psychological Association, one presenter identified the only risk of integrated care as being that it is not occurring rapidly enough.

We at the Centers for Family Change have recognized and stressed the value of coordinating our treatment efforts with others (school personnel, physicians, EAP staff, and other professionals) since our inception.  Several of our founders were trained in Community Mental Health, which stressed the importance of coordinated treatment efforts. However, we have and continue to strive to be sensitive to the benefits and risks of coordinating and integrating care.  Specifically, while increased communication between clinicians, school personnel, physicians, and EAP staff frequently allows for improved quality of care, there are risks to such communication. These include: increased risk that confidential information will be released or that more information than necessary will be released/shared with others, compromising clients’ privacy; a possible devaluing of rights to privacy (e.g., some therapy clients do not want their information shared with others); and a danger that the integrity of psychotherapy will be compromised if clients have to be concerned about who may access their records (we need to remember that one of the foundations of therapy is that it is a safe and protected place to share one’s most personal thoughts, feelings and experiences).

We have to keep in mind that there are instances where it likely more appropriate to not share information. For example, a couple seeking marital therapy may not want their issues shared with their primary care physician, particularly when they are not experiencing physical symptoms and have had limited interactions with their physician. Other examples, include families that decline to share information about their child with school personnel, when the child is not having problems within the school setting. Moreover, there may be an insidious impact on requiring the sharing of information. Individuals may become more guarded in therapy and thus limit the efficacy of therapy.

We are the Centers for Family Change are continuing to do our best to balance the competing pressures for integration and for sharing of information, with a respect for our clients’ privacy and the importance of maintaining therapy as a private and safe place for our clients. Specifically, we have found that the most effective strategy is to openly address and discuss these issues and challenges with our clients and to decide collaboratively with our clients when and what information they want shared. Not only is this process more respectful to clients, but it offers an opportunity to help our clients examine and consider their understanding of the concerns and problems involved in sharing and not sharing information.  Obviously, we are aware that there are a few instances when the refusal to share information may be problematic. If we believe that this may be the case we raise and address these issues with our clients. It is our experience that some concerns stem from unrealistic fears (e.g., that school personnel want to “railroad our child”). In these instances we try and address our clients’ concerns (and the fears that may underlie their hesitation to share information) while also being clear regarding the potential negative impact of not sharing information when this clearly is called for, e.g., to physicians prescribing psychiatric medications, to school personnel working with children who are struggling in school and at home, and with EAP professionals working with clients whose work place has mandated their treatment. Unfortunately, there are a few instances in which clients resist sharing information, e.g., a client who is abusing his/her prescription medications. In these instances we will more directly confront these issues and evaluate the appropriateness of continuing treatment.

Clearly, the issues of integration and coordinated care are going to remain a challenge for all of us. An additional component of integrated care involves electronic records. Electronic record keeping systems pose a particularly daunting and complex issue that is beyond the scope of this short article, but given their increased prominence in the integration of care the risks associated with electronic record keeping need to be carefully evaluated. In closing, it behooves all of us to be cognizant of the challenges that sharing of information pose. While sharing of information and coordination of care are often valuable we need to carefully consider the potential risks and negative consequences that may occur when we share our clients private and personal information.