Patient confidentiality in mental health and substance abuse treatment vs. integration of care

With health care pushing in the direction of integration of care and Partnership’s interest in integration as we implement the new Medi-Cal mild-to-moderate mental health benefit and our Managing Pain Safely initiative, a significant bone of contention involves protecting the patient’s right to and expectation of privacy when receiving mental health or substance abuse treatment.

This topic is being debated at the highest levels of government and healthcare in the state and nation. It goes beyond understanding what is HIPAA-compliant in terms of releases of information (ROI). Even if we cover ourselves legally with detailed release forms, the issue remains whether the goal of improved health care is defeated when integration efforts jeopardize the patient’s confidence in his/her mental health or substance abuse provider or cause the patient to withdraw from the very treatment that is supposed to boost the efficacy of primary care interventions.

The purpose of this blog post is to open the conversation and help understand the dilemma.

Q: What is the difference between mental health and substance abuse treatment and other forms of medical intervention?

A: I will start by reminding everyone that “therapize” is not a verb. Psychotherapy or alcohol and other druge (AOD) treatment is not something providers DO to someone. Parents can refuse immunizations for their children; however, when they do consent, someone simply sticks a needle in the little one’s arm and it’s a fait accompli. Not so with therapy. Unfortunately therapists and AOD counselors are often viewed by family members and the medical profession as the “behavior police.” Surely, as a seasoned therapist, I should be able to get rebellious Sonny to stop sniffing glue, philandering Hubby to cease his affairs, depressed Mommy to get up off the couch, non-compliant Mrs. Potts to take her insulin, and stubborn Mr. Potts to sign that consent for a life-saving operation. No, I can’t. Nor can you, the PCP, nor the family member who sent the person to me for the magic cure. Not that positive change can’t happen. But when it does, it is because a special relationship grows between the patient and the therapist, creating a level of trust within which change can occur. And this relationship relies on confidentiality, as much as on expertise. While patients may want to know where their provider got his/her degree and what degree they have, they care more about whether the therapist can keep sacred the most devastating secrets of their lives.

Q: What if it’s a matter of life or death?

A: Urgent issues involving danger to self, others, or being gravely disabled do not fall under the confidentiality mandate—in such instances, any and all who need to be involved to ensure patient safety are contacted. Even in these cases, however, further information about the nature and location of treatment are released only with patient consent.

Q: How willing are therapists to divulge information?

A:   PCPs understandably want to know whether a referral to mental health or substance abuse treatment has been followed up on by the patient. During the last 18 years of my career as a therapist at Kaiser Permanente, PCPs who were managing psychiatric medications were appreciative when I could give them feedback about the efficacy and side effects of prescribed medication and general information about improvement or exacerbation of symptoms in our mutual patients. It allowed them to make appropriate adjustments in medication. This information was exchanged with a proper ROI. Not all therapists, however, feel competent nor willing to relay such information to the patient’s PCP. A recent survey of our Beacon Health Strategies’ providers (89. or 18% of the total, replied) indicated that, with proper ROIs, 54% would be willing to maintain ongoing contact with PCPs, 35% percent would respond to specific PCP requests for information, and only 11% would not communicate with a PCP regardless of a release. This is a positive sign. The task, then, is to obtain proper ROIs.

Q: What are some ways to promote an exchange of information without damaging patient trust?

A: My advice on this subject can be boiled down to one word: ASK. When making a mental health or substance abuse referral, ASK the patient if they would consider signing a release with their mental health provider to exchange information with you because you are interested in their welfare. Emphasize that you DO NOT need or even want to know what is discussed in their therapy, just whether they have found it beneficial and that this feedback can aid in future treatment decisions on your part. This would accompany your usual instructions to call you or your staff if there are side effects, adverse events, or lack of efficacy. Beacon Health Strategies, our contracted vendor of mental health services, will also be encouraging their providers to request that new patients sign an ROI at the start of treatment.

Q: Do you need to know if the patient is in treatment to inquire about mental health or substance abuse issues?

A: No. If you are a PCP or care manager and have concerns about mental health or substance abuse issues, you can add the following to your regular diagnostic inquires: Are you currently receiving any mental health or substance abuse treatment? This way the patient is in charge of divulging the information. If their answer is YES, you can then gently inquire about how it is going. If their answer is NO, you don’t have to question whether they are telling the truth, simply add a recommendation for them to consider such treatment and offer referral resources, even if it’s for the fifth time!

Q: Should a patient’s mental health and substance abuse treatment be tracked automatically and be available through digital databases to PCPs and care managers?

A: I would not recommend this. It could inadvertently put care coordinators, care managers, and PCPs in the position of “big brother” or “intrusive codependent mother,” implying that the patient’s decision to get therapy or alcohol/drug treatment is open to discussion with no regard for confidentiality. Nothing makes a person more reluctant to stay on the wagon or seek mental health help than someone else passing judgment on their degree of commitment to such treatment. We need to give our patients the same dignity of choice that we value in our own lives. The only exception would be information on psychoactive medications prescribed by psychiatrists which, for reasons of safety, needs to be available to other prescribers to avoid adverse drug interactions.

Karen Stephen, Ph.D.

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