Reducing barriers to mental health care for student-athletes: An integrated care model
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Research suggests that National Collegiate Athletic Association (NCAA) Division I student-athleteshave higher levels of stress and other behavioral health issues, including substance use, than nonathletes. For several reasons, student-athletes may be less likely to admit to behavioral health issues and seek mental health care. Integrated care is a model of care that integrates behavioral health into a medical practice. This article explores the newly released NCAA Best Mental Health Practice guidelines and the application of integrated care to a Division I athletic training room setting using the three-worldview framework for successful integration, incorporating clinical outcomes, operational reliability, and financial stability.
Keywords: integrated care, student-athletes, primary care, collegiate athletes, mental health care
Approximately 400,000 National Collegiate Athletic Association (NCAA) student-athletes participate in 23 sports at more than 1,000 member institutions across the United States (National Collegiate Athletic Association [NCAA], 2007). Rates of depression for collegiate student-athletes range from 15.6% to 21% (Proctor & Boan-Lenzo, 2010), and freshmen are at greater risk than other collegiate class years to develop depressive symptoms (Trojian, 2016; Yang et al., 2007).
Student-athletes experience common mental health issues such as anxiety disorders, eating disorders, and substance use disorders (Yang et al., 2007). Despite inconsistent results (Wolanin, Gross, & Hong, 2015), the literature suggests that collegiate student-athletes are just as likely as the general population to experience depression and other mental health issues (Reardon & Factor, 2010). Student-athletes also undergo stressors not experienced by other college students; these include extensive time demands, pressures to achieve, injuries, burn out, and conflict with teammates or coaches. -If left un-addressed, these stressors and mental health issues experienced by the student-athlete may lead to increased anxiety and/or depression. Furthermore, concussions may increase depressive symptoms in student-athletes (Vargas, Rabinowitz, Meyer, & Arnett, 2015). However, because of stigma about mental health, fears that coaches/administration may not be supportive, or other causes, student-athletes may be less likely to acknowledge mental health issues and seek appropriate care (Proctor & Boan-Lenzo, 2010; Wolanian et al., 2015). Since collegiate student-athletes are less likely than nonathlete peers to seek help for depression, they may be at a greater risk of suicide (Armstrong, Burcin, Bjerke, & Early, 2015).
The NCAA Best Mental Health Practices document states that mental health providers should be easily accessible to student-athletes and include multiple disciplines (e.g., athletic trainers, primary care physicians, licensed mental health providers, life skills support staff, and registered dietitians; NCAA Sport Science and the NCAA, 2016). One way to provide comprehensive care to student-athletes is using an integrated care model. Integrated care combines mental and medical health services to form a unified, on-site team and integrated treatments, systems, and payments (Peek & National Integration Academy Council, 2013). The foundation of the model is biopsychosocial-spiritual (Engel, 1977; Wright, Watson, & Bell, 1996) and combines medical and behavioral health services to help patients who present to primary care (Peek & National Integration Academy Council, 2013) and tertiary care settings.
There are varying levels of integration (Heath, Wise Romero, & Reynolds, 2013). Levels range from 1-6(1 = minimal collaboration to to 6 = full collaboration). As seen in Table 1, providers in level 1 work in separate systems and facilities, rarely communicate, and have little appreciation of each other's skills. In a level 6, mental health and medical providers share systems (e.g., medical records, financial) and facilities, appreciate each other's roles, and work together in the biopsychosocial-spiritual framework (McDaniel, Doherty, & Hepworth, 1992). The Mental Health Best Practices document (2016) suggests an increase in collaboration between mental health and physical care to provide comprehensive services to student-athletes. As noted in Table 2, the NCAA Mental Health Best Practices document notes that a student-athlete's well-being is best served through a collaborative process in which the mental health provider is easily accessible and within or proximate to athletic department facilities, an interdisciplinary team consists of primary care and mental health providers, and the interdisciplinary team reviews the medical care of student-athletes. We combined the levels of integration with best practices to highlight that there may be a desire to combine mental and physical health practices. The levels, however, do not reach levels 5 or 6. One may assume that the levels are not higher due to a lack of knowledge about integrated care and how to implement such models in sports medicine.
Incorporating an integrated care model into the athletic training room can provide a student-athlete with comprehensive care and may reduce the stigma of mental health. We present our integrated care model in a NCAA Division I athletic training room, using the three-world view (Peek & Heinrich, 1995) framework that incorporates clinical, operational, and financial components. We describe implications of the framework, and recommendations for building an integrated care model in an athletic training room that align with the 2016 NCAA Mental Health Best Practices (NCAA Sport Science Institute and the NCAA, 2016).
Clinical
Incorporating instruments to assess health of student-athletes may be beneficial to identify issues, provide referrals to mental health providers, and track health outcomes over the course of care. About 40% of NCAA Division I University athletic training rooms use screening instruments to assess student-athletes for mental health issues, that is, depression, anxiety, substance use, mood disorders, and attention deficit hyperactivity (Sudano & Miles, in press).
One excellent opportunity for incorporating mental health into medical care is the preparticipation physical examination (PPE), which all student-athletes must complete before participating in his or her collegiate sport. Our program revised our intake form for PPE screening to include mental health questions such as, "Have you ever been diagnosed with and/or sought treatment for (Mark all that apply)." Options include anxiety, depression, attention deficit/hyperactive disorder (ADHD), substance use, sleep disorder, bipolar disorder, personality disorder (PD), obsessive-compulsive disorder (OCD), oppositional defiant and/or conduct disorder (ODD/CD), grief, or other. Importantly, like the medical PPE assessment, the PPE mental health assessment screens for previous, not current, mental health issues.
Operational
The second aspect of building an integrated care model is monitoring operations: how to provide the services, if those services are well-executed (Peek & Heinrich, 1995), and how they can be evaluated for efficiency and further improvement. We created an operational workflow (see Figure 1) to outline a protocol for the primary care physician, including additional screening questions and referral to the mental health provider during the PPE process.
PPEs occur before student-athletes begin classes or athletic activities at a university. Each student-athlete rotates through various medical stations (e.g., primary care physician, orthopedist, optometrist) to review his or her medical history and be examined. The mental health provider also is present to evaluate any mental health concerns noted by the student-athlete.
Of mental health providers who practice on-site in athletic training rooms, 20% are present for two half-days a week (Sudano & Miles, in press). The frequency in which mental health providers are in the training room needs to be considered when scheduling appointments with a mental health care provider. Ideally, the mental health provider sees student-athletes once every two weeks, as one of the goals of the integrated care model. It is also helpful for the mental health provider to attend staff meetings with athletic trainers (ATCs) to identify barriers and/or concerns for student-athletes accessing care.
ATCs are often the first point of contact for student-athlete mental health issues (Neal et al., 2013). They contact the mental health provider directly to discuss the referral and schedule the appointment. Similar to a primary care physician who works in an integrated care model, the ATC then meets in person with the student-athlete and mental health provider (Houten & Johnson, 2013), usually in the athletic training room area in an exam room. The ATC introduces the mental health provider, briefly reviews the student-athlete's medical history, and summarizes concerns and goals for referral, encouraging collaboration among the team members. The mental health provider then asks the student-athlete if there is anything else that may be important to share with the ATC before the ATC leaves. After the ATC departs, the mental health provider and student-athlete meet for the rest of the scheduled time.
After the meeting, the mental health provider documents the encounter in the student-athlete's medical record and informs the ATC and primary care physician about assessment, diagnosis, and treatment. There is also in-person follow-up with the medical team when the mental health provider is onsite at the training room in a conference room. The interdisciplinary team meets bimonthly in the training room to review ongoing treatment plans for student-athletes and discuss any concerns.
Financial
Financial stability should be considered early in creating integrated care programs. One consideration is if the model is a good value (costs vs. benefits) to others. Of mental health providers who provide services onsite within a training room, 73% are compensated for their time (Sudano & Miles, in press). Generally, the mental health provider is either employed through the athletic department, student health services, sport-specific budgets (e.g., football, baseball, soccer), or billing the student-athlete's insurance.
At our institution, there is a sports medicine program within the Department of Family and Community Medicine, which has traditionally provided medical and ATC support to local athletic teams. There is support for expanding this role to provide more comprehensive health care for the university's student-athletes. As a result, the athletic department compensates for the mental health provider's time spent treating student-athletes through the athletic budget. However, other athletic programs may not have the financial ability to hire a mental health provider to provide services onsite and financial structure may be different across programs. Athletic departments or primary care sports medicine groups can consider adding the mental health provider to their budgets. To encourage sustainability, it is helpful to negotiate an agreement with the university's Athletic Director or other leaders to cover time spent providing mental health care to student-athletes. Table 3 illustrates the interdisciplinary team, responsibilities, and time spent performing tasks.
Implications
Building and sustaining an integrated care model within a collegiate setting may be challenging without a framework. Important steps in establishing that framework include building an interdisciplinary team, reviewing and revising protocols to increase integration of care, modifying documentation practices, and program evaluation.
Hiring a mental health staff who share a vision (Unutzer, 2014) with the ATCs is critical to the success of integrated behavioral health programs. In addition, the mental health provider should be familiar with the cultures of college-age individuals, and of athletics in particular.
Modifying operations and establishing protocols, procedures, and documentation are important steps to take before launching an integrated model. As suggested in the NCAA Best Practices document (NCAA Sport Science Institute and the NCAA, 2016), we recommend reviewing protocols and assessment procedures in the training room to identify opportunities for integration, for example, PPEs. Universal screening, however, is not recommended given the limited resources likely to be available for student-athletes' mental health care. The interdisciplinary care team can create a list of providers in the community or on campus so that a student-athlete can be referred to a mental health provider, if needed.
Providers working in an integrated care model document findings and care plans in the same medical chart. This openness could, however, have implications for a student-athlete. The ATC and physician are bound by confidentiality but not to the same extent as a mental health provider in a collegiate athletic setting. For example, if a student-athlete were abusing a substance that interferes with the student-athlete's health, the ATC is obligated to report this information to the team physician due to the inherent risk of death during sports participation. In general, the ATC and team physician would not bring this information to the administration or head coach(es) and would treat the student-athlete accordingly. However, each institution has a different policy of reporting to the head coach and administration. The integrated care team, then, needs to recognize what is needed to protect student-athletes from all harm (NCAA Sport Science Institute and the NCAA, 2016) and know the institution's policy on reporting substance use. Considerations for documentation include what is kept separate from a student-athlete's medical chart so the student-athlete is protected and to maintain a relationship of trust. In an integrated design, a mental health provider documents only information pertinent to the treatment of the student-athlete in the medical chart, notifies the student-athlete of disclosure of substance use information, and, if necessary, separate records can be kept with detailed information.
A student-athlete's mental health and physical health status should be considered equally important. For example, after a musculoskeletal injury or concussion, an athlete must be cleared to return to play. Similarly, after a significant mental health event, it is important to establish that athletes are not a danger to themselves or others, and that the stress of athletic participation would not hinder their mental health recovery. Given the highly variable presentation and course of mental health events, a slow progression back to activity based on an athlete's response may be necessary; such a situation requires acceptance by the medical and coaching staff. Screening student-athletes at the PPE for previous and current mental health issues can allow the medical team to provide support for that student-athlete and set up services proactively (NCAA Sport Science Institute and the NCAA, 2016).
Conclusion
In this paper we present one method of establishing an integrated care practice model of care for student-athletes. There are, however, different models of integrating behavioral or mental health into such programs (Heath et al., 2013). In addition, barriers to increasing the integration of care can include, but are not limited to, physical space, organizational infrastructure, and other institutional resources (NCAA Sport Science Institute and the NCAA, 2016. There is need for program evaluation of integrated care models in sports medicine settings. Evaluation should include quantitative analysis of clinical outcomes (e.g., PHQ-9, GAD-7), operational (e.g., the student-athlete show rate for mental health appointments through integrated care services vs. referral to the university's counseling center), and financial (e.g., hospitalization, missed practices and games). Finally, in-depth interviews to explore the student-athlete's experience of integrated care should be conducted to assess student-athlete satisfaction and improve an integrated care program within a collegiate setting.
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Laura E. Sudano, PhD Wake Forest School of Medicine
Greg Collins, ATC Wake Forest University
Christopher M. Miles, MD Wake Forest School of Medicine
This article was published Online First November 28, 2016.
Laura E. Sudano. PhD, Department of Family and Community Medicine. Wake Forest School of Medicine: Greg Collins, ATC, Department of Athletics, Wake Forest University; Christopher M. Miles, MD, Department of Family and Community Medicine. Wake Forest School of Medicine.
Correspondence concerning this article should be addressed to Laura E. Sudano, PhD, Department of Family and Community Medicine, Wake Forest Baptist Medical Center. Medical Center Boulevard. Winston-Salem, NC 27157. E-mail: [email protected]
Received February 27. 2016
Revision received September 23, 2016
Accepted October 11, 2016
Table 1 Levels of IntegrationDomain Level Description Coordinated key 1 Minimal collaboration element: Providers work in separate facilities, are on separate systems, rarely communicate about communication patient care, never meet in person, separate funding/billing, do not have understanding of each other's roles 2 Basic collaboration at a distance Providers work in separate facilities, are on separate systems, periodically communicate about patient care, separate funding/billing, may meet in person within community.
have appreciation of each other as resources Co-located key element: 3 Basic collaboration onsite physical proximity Providers work in the same facility but not same office, are on separate systems, regularly communicate about shared patients, separate funding/billing, sometimes meet to discuss patients, are part of ill-defined team 4 Close collaborative onsite with some system integration Providers work in the same space within the same facility, share some systems like medical records, communicate in person as needed, consult as needed, separate billing and funding but may share grants, have a basic understanding of roles and culture Integrated key element: 5 Close collaboration approaching an integrated practice practice change Providers work in the same facility where they share some space, seek system solutions together, frequently communicate in person, collaborate driven by team culture, blended funding based on contracts/grants/agreements and billing is combined, understanding each other's roles and culture 6 Full collaboration in a transformed/merged integrated practice Providers work in the same space within the same facility, sharing all practice space, resolved most or all system issues to function in one system, consistently communicate as a team, collaborate driven by concept of team care, integrated funding based on multiple sources of revenue/billing practices are on a single billing structure, have roles and cultures that blur together
Note. Heath, B., Wise Romero, P., & Reynolds, K. (2013, March). A review and proposed standard framework for levels of integrated healthcare. Washington, DC: SAMHSA-HRSA Center for Integrated Health Solutions.
Table 2 Cross Walk Between NCAA Mental Health Best Practices and Level of Integration
NCAA Mental Health Best Practices (2016) Level (a)
Student-athlete mental well-being is best served through a collaborative process... Such integration links professionals in a collaborative model of care that can enhance the ability of individual service providers and maximize support of student-athlete wellness. (p. 5. para 5) 3 Evaluation and treatment of student-athletes should be coordinated through the primary athletics health care providers. (p. 7, para 1) 3 This practitioner Imental health] should be easily accessible to student-athletes... providing office space within or proximate to athletics department facilities is an important way to increase the practitioner's visibility and accessibility. (p. 8, para 1) 4 Each campus should establish an interdisciplinary team... can include primary athletics health care providers (ATCs and team physicians), [licensed mental health counselors], life skills support staff, registered dietitians, peer support specialists. (p. 8, para 2) 4 Coaches, administrators or other nonclinical staff within athletics who are concerned about the mental health of a student-athlete should communicate their concerns through... primary athletics health care providers (athletic trainers and team physicians). (p. 11, para 4) 2 Mental health screening questionnaires be part of the pre-participation exam (p. 13. para 1) 4 Procedures be established specifying when and to whom symptomatic or at-risk student-athletes identified through this screening process will be referred. The decision about what screening questionnaire approach will be used should be made in consultation with the primary athletics health care providers and the licensed practitioners who are qualified to provide mental health services to student-athletes. (p. 13) 4 The athletics environment can help support positive psychological well-being among all student-athletes by normalizing care seeking and fostering experiences and interactions that promote personal growth, self-acceptance, autonomy and positive relations with others. (p. 14, para 1) 3 Primary athletics health care providers and the licensed practitioners who are qualified to provide mental health services to student-athletes meet on an annual basis... [to discuss] the institution's mental health care protocols. (p. 14, para 2) 4 Athletics administration, sports medicine personnel and licensed practitioners who are qualified to provide mental health services jointly review: 1) medication management plan, 2) transitional care. 3) financial support, 4) communication strategies, and 5) disability services and reasonable accommodation (pp. 15 and 16) 4
(a) Heath, B., Wise Romero, P., & Reynolds, K. (2013, March). A review and proposed standard framework for levels of integrated healthcare. Washington, DC: SAMHSA-HRSA Center for Integrated Health Solutions.
Table 3 Staff Roles and Responsibilities
Staff Number Responsibilities
Primary care sports medicine physician Faculty 2 Assessment, diagnosis, and treatment of general, musculoskeletal, and mental health issues. Event coverage, policy/protocol creation.
Fellow 2 Assessment, diagnosis, and treatment of general. musculoskeletal, and mental health issues. Event coverage.
Mental health provider Marriage and family 1 Assessment, diagnosis, and treatment for mental health therapist issues. Provides sport performance counseling.
Psychiatrist 1 Assessment, diagnosis, and treatment (psychotropic medications) for severe persistent mental illness. Substance use 1 Assessment, diagnosis, and treatment for substance use disorders. Athletic trainer 11 Prevention, evaluation (triage), treatment, and rehabilitation of injuries, illness. Coordination of care. Preparation of safety aspect of competition sites.
Staff Hours of
Primary care sports medicine operation physician Faculty
Minimum 2 hours
per day, 2 days per week and Fellow as needed
Minimum 2 hours per day, 4 days per week and Mental health provider as needed Marriage and family
therapist Varies, 2-4 hours per day, 3 days Psychiatrist per week and
As needed Substance use
As needed Athletic trainer Varies, 8-16
hours per day, 6 days a week
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