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<h2>Healthcare Providers Policy Planning:The Four Quadrant Model</h2>by nationalcThe NCCBH proposed model for the clinical integration of health and behavioral health services starts with a description of the populations to be served. This Four Quadrant Model builds on the 1998 consensus document for mental health (MH) and substance abuse/addiction (SA) service integration, as initially conceived by state mental health and substance abuse directors (NASHMHPD/ NASADAD) and further articulated by Ken Minkoff and his colleagues. 
 
This model for a Comprehensive, Continuous, Integrated System of Care (CCISC) describes differing levels of MH and SA integration and clinician competencies based on the four-quadrant model, divided into severity for each disorder: 
 
Quadrant I: Low MH-low SA, served in primary care 
 
Quadrant II: High MH-low SA, served in the MH system by staff who have SA competency 
 
Quadrant III: Low MH- high SA, served in the SA system by staff who have MH competency 
 
Quadrant IV: High MH-high SA, served by a fully integrated MH/SA program 
 
The Four Quadrant Clinical Integration Model 
 
Behavioral Health Risk/Status 
Quadrant I 
PCP (with standard screening tools and BH practice guidelines) 
PCP-based BH* 
 
Quadrant II 
Case Manager w/ responsibility for coordination w/ PCP 
PCP (with standard screening tools and BH practice guidelines) 
Specialty BH 
Residential BH 
Crisis/ER 
Behavioral Health IP 
Other community supports 
 
Quadrant III 
PCP (with standard screening tools and BH practice guidelines) 
Care/Disease Manager 
Specialty medical/surgical 
PCP-based BH (or in specific specialties)* 
ER 
Medical/surgical IP 
SNF/home based care 
Other community supports 
Physical Health Risk/Status 
 
Quadrant IV 
PCP (with standard screening tools and BH practice guidelines) 
BH Case Manager w/ responsibility for coordination w/ PCP and Disease Manager 
Care/Disease Manager 
Specialty medical/surgical 
Specialty BH 
Residential BH 
Crisis/ ER 
BH and medical/surgical IP 
Other community supports 
 
*PCP-based BH provider might work for the PCP organization, a specialty BH provider, or as an individual practitioner, is competent in both MH and SA assessment and treatment 
Stable SPMI would be served in either setting. Plan for and deliver services based upon the needs of the individual, consumer choice and the specifics of the community and collaboration. 
 
The Behavioral Health / Primary Care integration model above assumes this competency-based MH/SA integration concept within the behavioral health (BH) services offered and builds on the MH/SA integration model to describe the subsets of the population that Behavioral Health/ Primary Care integration must address. 
 
Each quadrant considers the behavioral health and physical health risk and complexity of the population and suggests the major system elements that would be utilized to meet the needs of the individuals within that subset of the population. 
 
The Four Quadrant model is not intended to be prescriptive about what happens in each quadrant, but to serve as a conceptual framework for collaborative planning in each local system. Ideally it would be used as a part of collaborative planning for each new HRSA BH site, with the CHC and the local provider(s) of public BH services using the framework to decide who will do what and how coordination for each person served will be assured. 
 
The use of the Four Quadrant Model to consider subsets of the population, the major system elements and clinical roles would result in the following broad approaches: 
 
QUADRANT I 
Low BH-low physical health complexity/risk, served in primary care with BH staff on site; very low/low individuals served by the PCP, with the BH staff serving those with slightly elevated health or BH risk. 
The PCP provides primary care services and uses standard BH screening tools and practice guidelines to serve most individuals in the primary care practice. 
 
Use of standardized BH tools by the PCP and a tracking/registry system focuses referrals of a subset of the population to the BH clinician. The role of the primary care based BH clinician is to provide formal and informal consultation to the PCP as well as to provide BH triage and assessment, brief treatment services to the patient, referral to community and educational resources, and health risk education. 
 
BH clinical and support services may include individual or group services, use of cognitive behavioral therapy, psycho-education, brief SA intervention, and limited case management. The BH clinician must be competent in both MH and SA assessment and service planning. 
 
The PCP prescribes psychotropic medications using treatment algorithms and has access to psychiatric consultation regarding medication management. 
 
The consumer of care, by seeking care in primary care, has selected a clinical home. Consistent with appropriate clinical practice, that should be honored. The primary care and specialty BH system should develop protocols, however, that spell out how acute behavioral health episodes or high-risk consumers will be handled. 
 
This will also lead to clarity regarding the clinical home of consumers with SPMI who are currently stable, which should be based upon consumer choice and the specifics of the community collaboration. 
 
QUADRANT II 
High BH-low physical health complexity/risk, served in a specialty BH system that coordinates with the PCP. 
The PCP provides primary care services and collaborates with the specialty BH providers to assure coordinated care for individuals. 
 
Psychiatric consultation for the PCP may be an element in these complex BH situations, but it more likely that psychotropic medication management will be handled by the specialty BH system. The role of the specialty BH clinician is to provide BH assessment, arrange for or deliver specialty BH services, assure case management related to housing and other community supports, assure that the consumer has access to health care, and create a primary care communication approach (e.g., e-mail, v-mail, face to face) that assures coordinated service planning, especially in regard to medication management. 
 
Specialty BH clinical and support services will vary based upon state and county level planning and financing; some localities may encompass the full range of services offered by specialty BH systems including: 
 
Specialty MH Services 
Crisis respite facilities 
24/7 crisis telephone 
Crisis residential facilities 
Mobile crisis team 
Crisis observation 23 hour beds 
Urgent care walk in clinic 
Locked sub-acute residential 
Inpatient (voluntary and involuntary) 
Dual diagnosis inpatient 
Hospital discharge planning 
Partial hospitalization 
In-home stabilization 
Outreach to homeless shelters 
Outreach to jail/corrections 
Outreach to other special populations 
Individual/family treatment /counseling 
Group treatment/counseling 
Dual diagnosis treatment groups 
Multifamily groups 
Psychiatric evaluation/consultation 
Psychiatric prescribing/management 
Advice nurse (medication issues) 
Psychological testing 
Services for homebound frail or disabled 
Specialized services for older adults 
Brokerage case management 
24/7 intensive home /community case management (ACT teams) 
School-based assessment and treatment 
Supported classroom 
Stabilization classroom 
Day treatment (adult, adolescent, child) 
Supported employment /supported education 
Transitional services for young adults 
Individual skill building /coaching 
Intensive peer support 
After school structured services 
Summer daily structure and support 
Specialty SA Services 
Sobering sites 
Social detoxification/residential 
Outpatient medical detoxification 
Inpatient medical detoxification 
Pre-treatment groups 
Intensive outpatient treatment 
Outpatient treatment 
Day treatment 
Aftercare/12 step groups 
Narcotic replacement treatment 
Residential Services 
Boarding homes 
Adult residential treatment 
Child/adolescent residential treatment 
Transitional housing 
Adult family homes 
Treatment foster care 
Low income housing (dedicated to BH consumers) 
Supports for SPMI / SED Populations 
Representative payee/financial services 
Time limited transitional groups 
Parent support groups 
Youth support groups 
Dual diagnosis education/support groups 
Caregiver/family support groups 
Youth after school normalizing activities 
Youth tutors/mentors 
 
The BH clinician must be competent in both MH and SA assessment and service planning. A specific standard of practice should be adopted that defines the methods and frequency of communication with PCPs. Note that this quadrant is where most public sector BH consumers currently can be found. 
 
QUADRANT III 
Low BH-high physical health complexity/risk, served in the primary care/medical specialty system with BH staff on site in primary or medical specialty care, coordinating with all medical care providers including disease managers. 
 
The PCP provides primary care services, works with medical specialty providers and disease managers (e.g. diabetes, asthma) to manage the physical health issues of the individual and uses standard BH screening tools and practice guidelines to serve most individuals in the primary care practice. 
 
Use of standardized BH tools by the PCP and a tracking/registry system focuses referrals of a subset of the population to the BH clinician. The role of the primary care or medical specialty based BH clinician is to provide BH triage and assessment, consultation to the PCP or treatment services to the patient, referral to community and educational resources, and health risk education. 
 
BH clinical and support services may include individual or group services, use of cognitive behavioral therapy, psycho-education, brief SA intervention, and limited case management. The BH clinician must be competent in both MH and SA assessment and service planning. The PCP prescribes psychotropic medications using treatment algorithms and has access to psychiatric consultation regarding medication management. 
 
Depending on the setting, the BH clinician may also serve as a health educator regarding lifestyle and chronic health conditions found in the general public (diabetes, asthma) or conditions found in at-risk populations (Hepatitis C, HIV). T 
 
These population-based services, as articulated by Bob Dyer, would include: patient education, activity planning; prompting; skill assessment; skill building; and, mutual support.iii In addition to these disease management services, the BH clinician might serve as a physician extender, supporting efficient use of physician time by problem solving with acute or chronic patients, as well as working with patients on medication compliance issues. 
 
Specialty healthcare and disease management programs could also integrate depression screening into a wide array of self management and rehabilitation programs, building on current research findings regarding the frequency and impact of depression in cardiovascular or diabetes populations. 
 
QUADRANT IV 
High BH-high physical health complexity/risk, served in both the specialty BH and primary care/medical specialty systems; in addition to the BH case manager, there may be a disease manager, in which case the two managers work at a high level of coordination with one another and other members of the team. 
 
The PCP works with medical specialty providers and disease managers (e.g. diabetes, asthma) to manage the physical health issues of the individual, while collaborating with the BH system in the planning and delivery of BH clinical and support services, which include those listed in Quadrant II. 
 
Psychiatric consultation is a key element in these most complex situations. The role of the specialty BH clinician is to provide BH assessment, arrange for or deliver specialty BH services, assure case management related to housing and other community supports, and collaborate at a high level with the healthcare system team. The BH clinician must be competent in both MH and SA assessment and service planning. 
 
In some settings, BH services may be integrated with specialty provider teams (for example, Kaiser has BH clinicians in OB/GYN working with substance abusing pregnant women). With the extension of disease management programs into Medicaid health plans, there is the likelihood of coordinating with disease managers in addition to healthcare providers. 
 
The BH clinician and disease manager should assure they are not duplicating tasks, but working together to support the needs of the consumer. A specific standard of practice should be adopted that defines the methods and frequency of communication.The author is the Director of Marketing and Communications at The National Council. The National Council for Community Behavioral Healthcare is a not-for-profit 501(c)(3) association. For more information, visit <a href=http://www.thenationalcouncil.org>http://www.thenationalcouncil.org</a>.Syndicated by <a href="http://www.therightarticle.com">The Right Article - www.therightarticle.com</a>