and utilization of case records (Reamer, 2018; Tate Woodsen et al., 2018). The concept of informed consent is a cornerstone principal within the practice of behavioral health care. In integrated care, a less than complete understanding of informed consent can create ethical challenges for the broad spectrum of providers. In integrated care, behavioral providers obtain informed consent from the patient to share specified behavioral health information legally and ethically. Obtaining informed consent properly allows the sharing of treatment information with other providers in the integrated practice or group (Hudgins et al., 2013). This sharing must be precise, or targeted, so that the patient understands what specific parts of their record are shared with whom within the practice. In other words, clinicians must ascertain which practitioners to share with, based on the patient’s consent and control. Behavioral providers often must practice differently than other healthcare providers when correctly applying informed consent principles. These requirements for behavioral providers are stricter, whereas other healthcare providers typically utilize the concept of “care coordination,” which allows greater latitude within and without the practice or organization to share and receive health information (Reamer, 2018). Additionally, there are unique informed consent issues for behavioral providers in integrated care, namely, issues surrounding treatment of minors. As Reamer writes, behavioral providers “who serve children in integrated health care settings must keep pace with various informed consent guidelines and requirements concerning minors’ right to obtain substance abuse treatment and mental health services without notifying colleagues in the health center or the child’s parents or guardians” (Reamer, 2018, p. 119). Reamer (2018) outlines four clinical standards that must be observed for consent to be valid. ● Avoidance of coercion and pressure. Patients rely on the guidance and feedback they receive from behavioral providers, and this influence must be used wisely by the providers. In other words, providers must exercise care to not inappropriately influence the patient when discussing consent, especially when discussing the limitations of sharing health information within integrated care setting. Patients must be free of unnecessary pressure when making decisions about consent. ● Patient’s capability of proper consent. Some patients, young children, individuals who experience psychosis, individuals with cognitive impairments, individuals under the influence of drugs and alcohol, and those with severe mental illness may not understand the exact nature of consent, and therefore the consent obtained may not be valid. Providers must be aware of these clinical situations and realize any consent obtained may be invalid, seeking legal clarification for consent under specific, exceptional conditions, or obtaining proper consent at a later time when the patient is fully able to comprehend their decision. ● Valid consent forms. The consent document or language must be carefully written to explain key aspects of the patient’s informed consent decision within the integrated care setting. Consent documents must not be vague or overly general, omitting details that encompass valid consent for the patient. As Reamer (2018) writes, behavioral providers should “include details that refer to specific information to be released to other providers in the integrated health care setting or to professionals outside of the organization. Typical elements include details of the nature and purpose of a
disclosure of information; advantages and disadvantages of disclosure; substantial or possible risks to clients, if any; potential effects on clients’ families, jobs, social activities” (p. 120). ● Termination of consent. Providers must clearly explain that consent can be revoked or terminated at any time by the patient. Helping the patient understand that their treatment is free from pressure or obligation is an important duty of the provider. Ordinarily, consent automatically expires on a specified date, and this expiration date should be clearly stated in the consent language or document. Reviewing the rights of the patient to withdraw from treatment and terminate consent are important steps to avoiding ethical and legal mistakes during treatment. Another issue in integrated care involves HIPAA provisions related to psychotherapy notes within the patient’s health record. According to Reamer (2018), psychotherapy notes are “defined as notes recorded in any medium by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session, and that are separated from the rest of the individual’s health record” (p. 121). This HIPAA- mandated issue of separation is key. Key HIPAA protections are lost If the psychotherapy notes are not kept separate in the health record, namely, the provider’s right to “not have to disclose psychotherapy notes to insurance companies or in response to a subpoena, unless a client provides consent or there is a court order requiring disclosure” (Reamer, 2018, p. 121). In 2009 the Health Information Technology for Economic and Clinical Act (HITECH) became law (42 CFR Part 2). Subtitle D of the HITECH Act, addresses the privacy and security issues regarding electronic transmission of health information via provisions that heighten the criminal and civil laws of the HIPAA rules, raising financial penalties up to $1.5 million for violations made by a covered healthcare provider, health plan or clearinghouse. Specifically, within integrated care, practitioners must adhere to this federal rule in relation to diagnosing, treating or referring patients with alcohol or substance abuse problems. According to Reamer (2018) this “applies to any individual or entity that holds itself out as providing, and provides, alcohol or drug abuse diagnosis, treatment, or referral for treatment. This would apply to any integrated health care setting that offers specific substance abuse–related services. That is, providers may have to redact information related to substance abuse treatment from the health record that health center colleagues can access” (p. 121). The National Center for Excellence for Integrated Health Solutions is a valuable resource for behavioral providers who are practicing within an integrated care setting. The Center is the creation of the combined energies of the Health Resources and Services Administration (HRSA) and the Substance Abuse and Mental Health Services Administration (SAMHSA). The Center functions as a resource to promote the growth of integrated care (physical health and behavioral health), especially for behavioral providers who treat patients with substance use and mental illness problems. The Center offers a variety of training, tools, and support for practitioners within integrated care settings, partnering with a variety of like-minded organizations such as the American Psychiatric Association, the Weitzman Institute Inspiring Primary Care Innovation, the National Association of State Mental Health Program Directors Research Institute, and the Primary Care Development Corporation (Reamer, 2018).
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