[Authors’ Note: This paper was supported by grants from the Health Resources and Services Administration: G02HP279900201 and M01HP31370.]
Introduction
A 2018 Annual Report from the Center for Collegiate Mental Health on college and university campuses reported a steady increase in the number of college students seeking mental health services (Center for Collegiate Mental Health, 2019). Yet, nationally and locally, universities are grappling with how to provide needed services despite limited resources (Blake, 2019; Xiao et al., 2017). Given this, an innovative pilot was created for the dual benefit of expanding integrated behavioral health field placements at one School of Social Work (SSW) while also providing more comprehensive integrated services at Campus Health (CH), the health care center for the student population at the flagship campus of a public university located in the southeastern United States.
Field placements connected to campuses broadly help forge connections between MSW programs, faculty, and administrators across different campus units (Meade, McLaughlin, & Woods, 2015). This paper describes how these connections were formalized with a new field site piloted on campus and outlines the resulting benefits that ranged from meeting the demand for behavioral health services, increasing the number and type of integrated behavioral health field placement sites, creating learning opportunities for MSW students placed in this innovative integrated setting, and expanding the collaborative capacity for various units across campus. Strategies for navigating campus environments where multiple offices and programs interact with students regarding their health and wellness are also addressed. In addition, the paper describes the specific MSW learning opportunities, examples of the social work skills utilized, and MSW supervision considerations. The collaboration and enhanced relationships between one SSW, CH, and other units on campus show promise for replication and sustainability. The model, an excellent training opportunity for social work students, also positively impacts students on campus, CH staff, and the broader campus community.
Behavioral Health Services in Campus Health (CH) Clinics
A wealth of evidence suggests that college students are experiencing an increase in the complexity, scope, and severity of mental health issues requiring treatment (Chan, Moore, Derenne, & Fuchs, 2019; Downs, Alderman, Schneiber, & Swerdlow, 2016). For many campuses, this increase in student need has not resulted in increased funding and resources within the college setting, leading to what is being labeled a mental health “crisis” by college medical providers (Xiao et al., 2017). In many college settings, students may initially be seen and assessed in their campus health clinic, where medical providers of varying backgrounds are already managing a multitude of medical concerns. In a recent survey of primary care services in college health conducted in collaboration with the American College Health Association, it was estimated that about 50% of all non-integrated CH clinics had non-prescribing behavioral health clinicians on staff (Readdean, Heuer, Hoban, & Parrott, 2019). This survey highlights the potential benefits of concurrent treatment of behavioral and physical health needs for students. The growth of primary care behavioral health models in which a non-prescribing behavioral health clinician is embedded in the primary care setting—such as social workers—is emerging as an increasingly popular model to more comprehensively meet the needs of student populations across campus (Downs et al., 2016; Readdean et al., 2019).
As the research expands in this area, the presence of behavioral health services has been identified as an important driver of collaborative care practices (Corso, Hunter, Dahl, Kallenberg & Manson, 2016; Levey, Miller, & DeGruy, 2012). In primary care settings broadly, the integration of behavioral health can contribute to some cost savings (Blount et al., 2007). Readdean and colleagues (2019) found significant correlations between higher levels of integration in campus health with the presence of behavioral health staff. A recent systematic review of the inclusion of social work services within integrated health settings showed social work-led services increased quality ratings in most studies and positioning social workers as members of integrated teams had an overall positive effect on health and service utilization (Steketee, Ross, & Wachman, 2017).
The Need for Integrated Behavioral Health Field Placement Sites
UNC-PrimeCare is the name of an integrated behavioral health program funded by the Health Resource and Service Administration (HRSA) Behavioral Health Workforce and Training (BHWET) program to train and expand the behavioral health workforce. Literature about the BHWET mechanism has been explained elsewhere (see Kepley & Streeter, 2018). Contributions to the social work literature have explained how this funding mechanism has impacted social work curricula and training in integrated behavioral health (Zerden, Jones, Brigham, Kanfer, & Zomorodi, 2017), recruitment of field placements (Zerden, Kanfer, Palmer, Jones, & Brigham, 2018), and outcomes for trainees (Putney et al., 2017; Rishel & Hartnett, 2018; Rubin & Kilgore, 2019). However, given the recent and evolving changes to health care systems across various sectors (i.e., academic medical centers, federally qualified health centers, outpatient practices), university and colleges campuses are a new venue to consider for expanding integrated behavioral health services. The benefits of this new CH social work partnership are three-fold: first, CH placements help MSW programs develop new sites, a constant effort for social work programs working to increase the number of quality field placements (Buck, Bradley, Robb, & Kirzner, 2012); second, these placements allow for new clinical learning environments for MSW students to train in integrated settings; third, this model can increase comprehensive services to improve the overall health of students on college campuses nationwide.
UNC-PrimeCare has expanded and developed more than two dozen field placement sites since its initial funding in 2014. For many BHWET programs, finding quality integrated behavioral health field sites remains a constant effort (Rishel & Hartnett, 2018; Zerden et al., 2018). For schools that are more rural or in smaller metropolitan areas, there are only a finite number of field placements available to recruit, especially those providing interprofessional, integrated care. When multiple SSWs are located in a shared geographic area, there are additional challenges identifying quality field placements for all students (Buck et al., 2012). In order to find new and innovative ways to expand integrated field placements, the project team considered potential ways for MSW students to be placed in health settings on campus. In 2016 the UNC-PrimeCare project director emailed the medical director at CH to suggest the inclusion of social workers as a way to expand behavioral health support in the clinic. The medical director of CH, who happened to be working to establish increased integrated behavioral health services in the clinic, followed up quickly. Given the shared synergies, the UNC-PrimeCare project team and the CH medical director realized placing an MSW student in CH could meet both stakeholders’ needs—expand field placement options and expand behavioral health services to the campus community. In fall 2017, the first student was placed in this newly developed site.
Field Placement and Supervision Considerations
CH does not currently employ an MSW, so a nurse manager and the medical director were identified as the on-site supervision team for the inaugural MSW student. This required the need for off-site field instruction, which was provided by the UNC-PrimeCare project coordinator hired by the BHWET grant. To ensure adequate oversight, the off-site field instructor met weekly with the student, was available to sit-in on occasional client sessions, was available by phone for emergency consultation, and communicated regularly with the on-site CH supervision team. In their role as task supervisors, the CH medical director and nurse manager provided daily support for the MSW student and coordinated the student’s activities and schedule while in the field placement to ensure that the student was well integrated into the daily flow of the CH clinic environment. Customary to our field processes, the MSW student, field faculty member, off-site field instructor, and CH staff met 3-4 times per year and collaborated on the student’s learning agreement and competency evaluations. These supervisory meetings were particularly important in creating the initial structure for the placement. To establish this, the supervisory team met to review the student learning agreement in depth, clarify the scope of the student intern role, and ensure that the placement provided ample opportunities for MSW students to fulfill all nine social work competencies highlighted in the 2015 Educational Policy and Accreditation Standards (Council on Social Work Education, 2015). Since the inception of this new field placement site, CH has hosted 3 MSW students who have completed year-long placements and the model is currently in place with a 4th student who will finish in May 2020. Currently, arrangements are underway for an additional MSW student to be placed at CH in the 2020-2021 academic year.
Social Work Opportunities within Campus Health
Within primary care integrated settings involving social workers as members of interprofessional teams, Fraser et al. (2018) identified three primary functions of social workers: 1) Behavioral health specialists; 2) Care managers, and 3) Community specialists to help with referral and linking of services. Based on student feedback and learning agreements, field instructor and task supervisor assessment, and the School of Social Work field faculty involved, it was evident MSW students at CH functioned within all of these roles and became valuable members of interprofessional teams. Below is a brief description of tasks and functions students performed as well as various skills practiced by MSW students working as part of an integrated team within CH.
Key Skills Utilized by MSW Students at Campus Health
The key skills students utilized in this new field placement that enhanced their direct practice training in integrated behavioral health care related to screening and assessment. MSW students also had opportunities to engage clients in brief interventions addressing issues ranging from sleep hygiene, academic and social adjustment concerns, substance misuse, eating disorders, pregnancy, depression, and anxiety. MSW students at CH benefitted from taking classes and supplemental trainings in integrated health, brief interventions, Cognitive Behavioral Therapy, Motivational Interviewing, substance use disorders, and differential diagnosis that made these topics relevant to their field placement and the 18-25 year-old target population of the initial BHWET grant. The MSW students collaborated with medical providers to identify resource and referral needs, and the students developed and provided psychoeducation materials when needed. There were opportunities for MSW students to attend trainings with other social work students placed at the university’s Counseling and Psychological Services (CAPS) offices, where students traditionally receive mental health care—a separate campus support that provides no physical healthcare. Through their work with patients and medical providers, MSW students were able to gain knowledge and skills in the social work core learning competencies of client engagement, assessment, and intervention.
Macro Skills
In addition to clinical skills, the CH field placement gave students the opportunity to advance their macro skills. MSW students placed at CH participated in campus and community policy and planning groups while also learning about the challenges that come with providing health care across a large university system. This allowed each student to pursue activities that interested them most based on specific populations and social problems. One student identified needs of LGBTQ+ students and made recommendations to the CH administrators about making intake and other forms more affirming and inclusive. Another student increased the medical providers’ use of screening for binge drinking and other substance use concerns. A third student researched how CH providers documented sexual assault, leading to a better understanding of the pervasiveness of these problems among students seeking CH services. Students were easily able to link their macro learning projects to research, policy, and evaluation-related core competencies within the student learning agreement.
Outcome of the SW and CH Collaboration
In meetings with the SSW team, the CH staff and administrator communicated that having MSW students placed at CH raised the awareness of the leadership team about the benefits of embedding social workers in primary-care settings. The CH providers also described both short- and long-term benefits of the students’ work on new screening tools and assessments, on a library of issue-specific resources for providers to use with students with specific mental health and/or circumstantial challenges, on revising forms to be inclusive for LGBTQ+ clients, and on community resources for pregnant students. In addition, the MSW students have improved communication and workflow between CH and CAPS, which often share a client base and entry point for students seeking mental and behavioral health services.
From Students to Professionals
The MSW students who trained at CH were desirable hires for newly created university and health system jobs. Since 2014, all three MSW students who completed their field placements at CH have been employed by the University of North Carolina at Chapel Hill in different units and programs. The School of Medicine hired the first student as their inaugural Student Wellness Coach (a position that is being expanded to include two social workers). The Office of the Dean of Students hired the second student as a case manager, and the third student was hired by CAPS. Students reported that completing their field placements at CH instilled a passion for working with college-aged students and young adults. As students, they collaborated with many campus departments, giving them an advantage when applying for jobs with the University. These cross-campus relationships made for a seamless transition once the former students transitioned to being new employees within the university.
Necessary Steps for Replication
Understanding the unique needs of primary care on college campuses requires efforts from multiple perspectives and units on campus. The supervision provided by the UNC-PrimeCare coordinator was instrumental in getting this new field placement going. Given there is likely not an MSW in these settings across campuses, MSW supervision is a considerable barrier. While this project had grant funding to support this new field placement, in instances without such funding, perhaps a faculty member with workload or overload needs, or an adjunct instructor, could provide the supervision as an off-site field supervisor. Another necessary component was ensuring CH staff and administration understood the benefits of having an MSW student in-house. This required tracking of tasks, functions, and effort so that the pilot could be assessed and adapted in subsequent years. In this case, the buy-in from the CH medical director was a tremendous support in developing this field placement. However, even if this is not the case initially, it is incumbent upon social work leadership to help promote the role of social work and the ways MSW students can be utilized across campus in various meetings and campus-wide events. Another idea is for field directors and faculty engaged in field education to consider possible campus units and offices where expanded field placements are possible. Campus Health Clinics, separate from CAPS and university employee and student wellness programs, provide a unique learning environment for students interested in being part of an integrated health care team that provides both physical and behavioral health services.
Conclusion
This paper highlights strategies taken to create a new integrated field placement between the MSW program and Campus Health Clinic at one university. This field placement helped expand the number of integrated behavioral health field placement sites and gave MSW students new opportunities to gain core social work competencies and experience training as part of an integrated team. An additional benefit of this collaboration was expanded services, and a social work perspective gained in the care delivery of a Campus Health Clinic. Overall, the development of this field placement helped strengthen the number and type of field placements in an otherwise fairly constrained environment, and, ultimately, helped to expand the reach and role of the social work profession.
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