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June 28, 2012

When administrators at the University of Georgia decided to merge their health and counseling centers about a decade ago, they were among the first to do so. And while the idea was pioneering in theory, it didn’t play out so well practically, a former director of the center says.

New service fees rose, blocking students from access to health professionals. The counseling center’s well-established pre-doctoral internship had to be cut because it didn’t fit in with the health center model. And, in what the director said amounted to more of an absorption than a merger, counselors were left wondering why their services were less valued than those of their medical colleagues. Those counselors ultimately left, the director says. And to top it all off, the merger didn’t produce the anticipated revenue savings.

“Our culture was destroyed. We basically were asked to come into the health clinic and operate under their standards…. It really was closing the counseling center,” said Steve D. Brown, the former director at Georgia who is now director of the counseling center at East Tennessee State University. “This is just one case; I mean, there are so many cases where it’s been hard on people.”

Dealing with shrinking budgets, more students and more serious health problems in patients, many institutions (92, according to a 2010 survey by the American College Health Association) are opting to integrate wellness services. But as the idea becomes increasingly popular, some health professionals – in counseling especially – worry that its feasibility and benefits might not live up to expectations.

"An organization that provides a holistic approach to students offers better quality care, better continuity of care, safer patient/client care, and more accessible care."
--Jean Chin, health center director at U. of Georgia, on 2005 merger with the counseling center

Health and counseling center integration was a hot topic a few weeks ago at the annual ACHA conference, and discussion got heated. The merger trend fits in with a larger pattern of collaboration between departments to better-address a student’s needs; the best example is probably behavioral intervention or threat assessment teams, which took off after the 2007 shooting at Virginia Tech University and bring together doctors, psychiatrists, administrators and police to identify and monitor potentially troubled students.

The idea, of course, is that everyone brings their unique expertise to the table, for a more holistic and thorough treatment of each student. But in the case of the mergers, some professionals are asking whether their input matters as much as it should – and whether integrating is even worth it.

“This is probably the most controversial issue in the counseling center world these days,” said Dan L. Jones, director and chief psychologist of the counseling and psychological services center at Appalachian State University and president of the Association for University and College Counseling Center Directors. “My concern is that it’s being treated as though it’s best practice and it’s a fact that it’s more streamlined…. There are a lot of strong opinions, but there’s not a lot of evidence to support the assertions that are being made in a factual way.”

While health centers operate in a clinical model, focused on treatment, counseling centers under the comprehensive student developmental model more often emphasize outreach, health promotion and prevention. Reconciling those two philosophies can be complicated, and it’s the developmental aspects --  the promotion, outreach and education -- that counselors worry could be lost in the mix. 

“These are professions, and professions have kind of always been siloed,” said Jennifer Haubenreiser, ACHA president and director of health promotion at Montana State University. “I think that’s just a strategy, that when you approach something collaboratively and comprehensively and in an integrated model, you can increase efficiencies that way.”

“Our culture was destroyed.... It really was closing the counseling center.”
--Steve D. Brown, former counseling director at Georgia, on the merger

Jean Chin, who took over as Georgia's health center director in 2005, could not speak to the process or immediate effect of the integration because it pre-dated her employment there. But since then, administrators have added more counseling and psychological services (CAPS) staff as well as 30,000 square feet of space, a third of which is dedicated to CAPS services. Further, she said, the only obstacle to students' access of health services is increased wait times as demand has gone up; 14,673 students visited CAPS in 2012, 13.8 percent more than the year before.

"Since I became the executive director, it was my goal to create a seamless, holistic experience for students when they came to the health center where health promotion and wellness, counseling and psychiatric services, and medical services would exist as our core services, very much like the three legs that support a stool. Each component is necessary to support the overall health of a student," Chin wrote in an e-mail message. "An organization that provides a holistic approach to students offers better quality care, better continuity of care, safer patient/client care, and more accessible care."

Centers that are merging are doing so to various degrees, depending on the needs of the campus. The ones that are fully integrated share space, records, administrators and managers. Others might just share a building.

The key, professionals who have studied the idea say, is ensuring the administrators who execute a merger understand everyone’s role and value everyone’s input.

“The programs I know that have had troubles, it was more a top-down thing,” said Jamie Davidson, assistant vice president for student wellness at the University of Nevada at Las Vegas, and chair of ACHA’s mental health section. You can’t think of it as just pulling counseling into the health center, he said. “You really have to know and appreciate and realize you’re creating a new entity.”

In a survey of institutions for a 2010 ACHA white paper on counseling integration, three in four integrated centers said integrating helped them better meet student needs, and 63 percent reported efficiencies in processes such as referrals and record-keeping. Other widespread improvements included staff communication, and utilization and quality of services. (Most of the institutions merging health services are either larger universities with separate departments, Davidson said, or small colleges with just a few staff.)

But about 9 percent said integration decreased the efficiency of administrative processes, and 7 percent said staff morale took a hit. Still, Davidson is getting more calls than ever from campuses asking about integration. “We’re seeing more and more places do it,” he said. “It definitely feels that that’s the way we’re going.”

UNLV integrated its centers in 2001, Davidson said. There, staff across the board – from primary care providers to women’s center coordinators – are trained to “look at all of the dimensions of a person’s existence.” In other words, a student who visits the women’s center to talk about an abusive relationship and shows signs of depression could be walked over to see a counselor or doctor (or both).

Mental, physical, social and academic well-being coexist and are interrelated; they’re not mutually exclusive. So when treating one, merger proponents say, it makes sense to be aware of the others. Take alcohol abuse, an obvious example that has impact on all those aspects of a student’s health and might require treatment for those different aspects as well.

“We’re all working in an integrated way toward student success and their mental well-being. If they’re having financial stress, if they’re having academic stress, if they’re having relationship stress,” Haubenreiser said, “if they’ve got a chronic health issue. And having that care available right here in the campus community, I think is a real asset.”

The idea continues to generate discussion. The AUCCCD, the counseling center directors association, is gathering data for a white paper about the different structures and functions of counseling centers that should be carefully considered in mergers. And Davidson wants to assemble a list of best practices based on successful integration stories. Integration will be a sub-theme of next year’s ACHA convention.

“We’re essentially all at the same table, having a conversation that’s both clinically and environmentally focused,” Haubenreiser said. The complexity of issues facing students and the health centers they rely on, she said, “almost requires that we come together as a team.”

 

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