Eye on Ethics

Ethics and Integrated Behavioral Health
By Frederic G. Reamer, PhD
November 2017

One of the most encouraging developments in the human services is the advent of integrated behavioral health. The core feature of this model involves recognizing and addressing the complex connections between physical and mental health, a phenomenon well understood by social workers, who have always appreciated the intimate connection between mind and body.

In recent years professionals have grown to appreciate the need to connect these dots in order to assist people. Health care professionals—e.g., physicians, physician assistants, nurse practitioners, nurses, and physical therapists, among others—need to understand how their patients' mental health challenges can affect their physical health. Similarly, social workers and other mental health professionals need to understand the ways in which clients' physical health challenges can affect their emotional well-being. The concept isn't complicated, although true articulation can be challenging.

According to the federal Academy for Integrating Behavioral Health and Primary Care, an estimated 26% of patients seen in primary care settings meet criteria for a mental disorder; however, a relatively small percentage of people with mental disorders receive any form of treatment (approximately two-fifths). Further, research summarized by the Academy suggests that while more of these people receive treatment in primary care than in any other setting, the treatment provided in the primary care setting typically does not meet minimal standards of care.

Many health care historians assert that the first integrated behavioral health program was the Gouverneur Health Program, which began in the 1970s in New York City, although the model did not begin to flourish until the 1990s. In the early 2000s the U.S. military and the Health Resources and Services Administration—the primary federal agency for improving health equity—promoted the model. In the private sector, Health Partners in Minneapolis and Sharp Health in San Diego helped put integrated behavioral health on the map. A key byproduct of the Affordable Care Act, signed into law in 2010, was creation of the federal Academy for Integrating Behavioral Health and Primary Care, whose mission is to "help build behavioral health care into primary care" throughout the United States. Over time, the Academy has developed an ambitious research, education, and policy agenda, focusing especially on best practices. Key topics and issues include optimal ways to design and implement integrated behavioral health, finance integrated behavioral health services, measure outcomes, and provide education and training.

Ethical Challenges
Social workers applaud the emergence and maturation of integrated behavioral health. The concept resonates among professionals who seek to understand and address the complicated interplay between mental health and physical health.

That said, I have spent a great deal of time during the past couple of years fielding questions about ethical challenges that have surfaced because of these laudable developments. Nearly all of the queries concern social workers' efforts to protect clients' privacy and confidentiality. The following are several examples:

• A mental health center in a rural community has a primary care practice on site; clients receive medical care from internists, physician assistants, nurse practitioners, and nurses. A social worker's client is being treated in the health practice for diabetes and hepatitis C. The social worker provides supportive mental health counseling. The client is in recovery from opiate addiction. The client disclosed to the social worker that he is struggling with sexual orientation issues. The client told the social worker he would prefer to keep this information private, because he knows several clinic staffers socially; the client asked the social worker not to share these details with his primary health care providers. However, the electronic health record allows the primary health care staffers to access all of the social worker's notes.

• A neighborhood health clinic serves a large low-income community. About a year ago the clinic hired two full-time social workers to provide mental health services to clinic patients. A 16-year-old patient received medical care for a sexually transmitted infection (STI). The teen also received mental health counseling for anxiety symptoms. The teen told his clinic physician that he was embarrassed about the STI and did not want the social worker to know about it. However, the social worker had full access to the teen's electronic health record.

• A large health maintenance organization (HMO) provides enrolled patients with comprehensive health care, including primary care, behavioral health, orthopedics, dermatology, podiatry, ophthalmology, optometry, ob-gyn, gastroenterology, and rheumatology, among other specialty services. A group of social workers at the HMO became concerned that all staffers had access to the social workers' behavioral health care notes. They arranged to meet with senior administrators to express their concern that HMO staffers who ordinarily would have no reason to access social workers' clinical notes had viewed them.

Creating Privacy Protocols
The proliferation of integrated behavioral health programs has led to vigorous discussion about ways to protect the privacy and confidentiality of social workers' clients. We are in the beginning stages of efforts to develop meaningful and practical protocols consistent with prevailing ethical standards. For example, the Bazelon Center for Mental Health Law has developed "Health-Information Sharing for Collaboration Among Agencies," guidelines intended to promote constructive sharing of information among health care and behavioral health professionals. The following is an excerpt:

"For treatment purposes, there are few restrictions to sharing health information between two practitioners who are (or will be) treating the same patient. However, treatment information is often needed in other contexts, such as when an individual moves to the community from an inpatient or correctional setting where treatment was provided. In that context, collaboration between the entities involved is important. And when someone is applying for public benefits (SSI or Medicaid, for example), there may be specific rules about sharing health information with the administrative staff who will review the application. The critical factor is the individual's consent to the sharing of his or her health information. With the person's consent, information can always be shared unless there is a clear health and safety risk to some individual (a highly unlikely scenario for benefit applications). While practitioners operate under licensing rules and their profession's codes of ethics, these should not lead to restrictions on sharing information with consent."

Another helpful resource is the Center for Integrated Health Solutions, a collaboration between the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration. It has provided social workers and other behavioral health and health care professionals with a rich array of resources designed to promote integrated behavioral health care. Among these resources is a guide to pertinent confidentiality issues.

Social workers who are employed in integrated settings should be mindful of several key guidelines when they make decisions about documentation and disclosure of sensitive information. First, they should understand fully which colleagues can and should access their clinical notes. This may influence social workers' judgments about the extent to which they include sensitive information in their notes. Second, social workers should consult with appropriate administrators about establishing protocols, possibly including firewalls, to ensure that only staffers who have a need to know have access to social workers' clinical notes. Third, social workers should ensure that clients understand who will have access to information about their behavioral health counseling (consistent with the ethical principle of informed consent). Finally, social workers should ensure that their agencies comply with relevant federal and state confidentiality laws (including HIPAA and 42 CFR Part 2 at the federal level and various health care confidentiality laws at the state level) and pertinent standards in the NASW Code of Ethics (primarily section 1.07).

For good reasons, integrated behavioral health has come of age. Social workers who are employed in these settings should be vigilant in their efforts to ensure that clients' privacy and confidentiality rights are protected.

— Frederic G. Reamer, PhD, is a professor in the graduate program of the School of Social Work at Rhode Island College. He is the author of many books and articles, and his research has addressed mental health, health care, criminal justice, and professional ethics.