_____________________________ Ethics in Behavioral Health Documentation: Reasons, Risks, and Rewards
DOCUMENTING BEHAVIORAL PRACTICE WITHIN INTEGRATED CARE SYSTEMS
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 sur- rounding 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 guard- ians” (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).
The contemporary healthcare landscape continues to evolve in the direction of greater inclusion of behavioral providers in primary care (Riley & Freeman, 2019). Thus, integrated healthcare settings have greatly expanded in Western nations, with providers reporting preferences for integrated treatment teams (Lancaster et al., 2018). This is due, in part, to the introduction into law of the Patient Protection and Afford- able Care Act, which was enacted in 2010 (Maniss & Pruit, 2018), although the roots of integrated care delivery go back as far as the 1930s. Today, integrated care practices are com- monly offering “deliberate and sustained coordination of care among health care practitioners (physicians, nurses, nurse practitioners, and physician assistants, among others) and behavioral health professionals (social workers, psychiatrists, psychologists, mental health counselors, and addiction spe- cialists, among others)” (Reamer, 2018, p. 118). This growth of integrated care reflects the awareness that behavioral care is necessary and specialized, and that various providers need documentation that is accurate and standardized (Bruni et al., 2021; Chowdhury & Champion, 2020; Hosang et al., 2022; Reiter et al., 2018). Integrated care settings typically offer healthcare and behav- ioral care in one facility or on one campus, allowing patients to have easier access to services and providers. Typically, these care models utilize an electronic health record (EHR) that contains all pertinent healthcare information for each patient. Providers also typically collaborate to improve access to care, and they coordinate care across varying services for patients (Kariotis et al., 2021; Meeder, 2021). However, the integration of services creates a complexity of documentation sharing and related ethical issues for behavioral providers that manifest in the creation 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 provid- ers. 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, clini- cians 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
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