Applying the 4 Quadrant Healthcare Model and Evidence-Based Practices to Behavioral Health

APPLICATION OF THE FOUR QUADRANT HEALTHCARE MODEL TO VARIOUS POPULATIONS -

The examples used in the diagram of the Four Quadrant Integration model are for adult populations; the same template can be used to create models that are specific for children and adolescents, or older adults, reflecting the unique issues of serving those populations (for example, the role of schools and school based services in serving children). Older adults, particularly, have been shown to utilize primary care settings for psychosocial, non-organic somatic complaints and to be underrepresented in specialty behavioral health populations -- research suggests they are willing to receive behavioral health services in a primary care setting and that targeted interventions can make a difference in depression symptoms. Ethnic, language and racial groups also have unique issues in receiving language and culturally appropriate behavioral health services. Primary care based behavioral health services can improve access for these populations and lead to appropriate engagement with behavioral health specialty services as needed. For example, the Bridge Program in metropolitan New York has been successful in reaching the Asian-American community via their primary care settings.

There are also differences between rural and urban environments and among regional markets in terms of the resources available and ease or difficulty of access to services. The Four Quadrant Integration model provides a template for considering the resources locally available and developing alternative methods of coordination (for example, telemedicine) that may be required when specialty care (either physical or behavioral health) is delivered in another community.

The Four Quadrant Clinical Integration model is not diagnosis specific; it looks at degree of clinical complexity and risk/level of functioning. Further, the evidence-base is at different levels of development in each of the Quadrants. The model is intended to provide a conceptual construct for how to integrate services. Diagnosis specific guidelines should be used to provide detailed guidance for the scope of the primary care provider, the primary care based behavioral health provider, and the specialty behavioral health provider.


THE FOUR QUADRANT MODEL AND EVIDENCE-BASED PRACTICES IN HEALTHCARE AND BEHAVIORAL HEALTH -

In the healthcare system, there are numerous evidence-based practice guidelines that are diagnosis/condition specific. The National Guideline Clearinghouse (NGC) is a public resource for evidence-based clinical practice guidelines. NGC is sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services, in partnership with the American Medical Association and the American Association of Health Plans. There are over 1000 disease/condition guidelines that can be accessed through their website (www.guideline.gov).

The Chronic Care Model (CCM) (http://www.improvingchroniccare.org/change/index.html) was developed under the Improving Chronic Illness Care Program. The CCM is in use in a variety of healthcare settings, providing a structured approach for clinical improvement.

The CCM has been used to develop specific approaches for serving patients with diabetes, cardiovascular disease, asthma and depression in a project sponsored by the Bureau of Primary Health Care (BPHC) with the Institute for Healthcare Improvement (IHI), a not-for-profit organization driving the improvement of health by advancing the quality and value of health care. The Health Disparities Collaboratives (http://www.healthdisparities.net/) are a multi-year national initiative to implement models of patient care and change management in order to transform the system of care for underserved populations.

The organizing principles for each of Health Disparities Manuals follows the key elements of the CCM; many of the components apply to each disease entity (e.g., diabetes, asthma, depression), while specific tasks and tools are unique to the specific disease entity. The key change concepts found in the Depression Collaborative manual include:

Organization of Health Care/Leadership -

>   Make sure senior leaders and staff visibly support and promote the effort to improve chronic care
>   Make improving chronic care a part of the organization's vision, mission, goals, performance improvement, and business plan
>   Make sure senior leaders actively support the improvement effort by removing barriers and  providing necessary resources
>   Assign day-to-day leadership for continued clinical improvement
>   Integrate collaborative models into the quality improvement program

Decision Support -

>   Embed evidence-based guidelines in the care delivery system
>   Establish linkages with key specialists to assure that primary care providers have access to expert support
>   Provide skill oriented interactive training programs for all staff in support of chronic illness improvement
>   Educate patients about guidelines

Delivery System Design -

>   Identify depressed patients during visits for other purposes
>   Use the registry to proactively review care and plan visits
>   Assign roles, duties and tasks for planned visits to a multidisciplinary care team. Use cross training to expand staff capability
>   Use planned visits in individual and group settings
>   Make designated staff responsible for follow-up by various methods, including outreach workers, telephone calls and home visits

Clinical Information System -

>   Establish a registry
>   Develop processes for use of the registry, including designating personnel to enter data, assure data integrity, and maintain the registry
>   Use the registry to generate reminders and care planning tools for individual patients
>   Use the registry to provide feedback to care team and leaders

Self- Management -

>   Use depression self management tools that are based on evidence of effectiveness
>   Set and document self management goals collaboratively with patients
>   Train providers and other key staff on how to help patients with self management goals
>   Follow up and monitor self management goals
>   Use group visits to support self management

Community -

>   Establish links with organizations to develop support programs and policies
>   Link to community resources for defrayed medication costs, education and materials
>   Encourage participation in community education classes and support groups
>   Raise community awareness through networking, outreach and education
>   Provide a list of community resources to patients, families and staff


EVIDENCE-BASED PRACTICES IN THE BEHAVIORAL HEALTH SYSTEM -

The Chronic Care Model (CCM) has also been adapted by The National Program Office for Depression in Primary Care (http://www.wpic.pitt.edu/dppc/), to develop a clinical framework for all partnering organizations to follow. Its Flexible Blueprint was developed after a review of published interventions used to treat depression, interviews with a variety of primary care physicians, mental health specialists and other experts in the field, and selected site visits to view elements of the Chronic Care Model in action.

The Substance Abuse and Mental Health Services Administration (SAMHSA) is supporting the Implementing Evidence Based Practices Project. This project is focused on people who have severe mental illness; these people are most frequently served in the public mental health system (http://www.mentalhealthpractices.org/).

There are six areas that have been researched. Toolkits have been developed based on the multi-state demonstrations that have been underway. The six areas are described below, based on the website materials:

Illness Management and Recovery -

This is a program of weekly sessions where specially trained MH practitioners help people develop personal strategies for coping with mental illness and moving forward in their lives. The program emphasizes helping people set and pursue personal goals and become better able to realize their vision of recovery.

Medication Management Approaches In Psychiatry (Medmap) -

This focuses on using medication in a systematic and effective way, providing guidelines and steps for decision-making based on current evidence and outcomes, monitoring and recording information about medication results, and involving consumers in the decision-making process.

Assertive Community Treatment (ACT) -

This program is for people who experience the most severe symptoms of mental illness. The goal is to help people stay out of the hospital and develop skills for living in the community. Services are provided by a team of practitioners, are available whenever and wherever needed, 24-hours a day, and are provided for as long as they are wanted and needed.

Family Psychoeducation -

This involves a strong partnership between consumers, families and supporters, and practitioners. People work toward recovery by developing better skills for overcoming everyday problems and illness-related issues, developing social support, and improving communication with treatment providers.

Supported Employment -

This is a well-defined approach to helping people with mental illness find and keep competitive employment. These programs are for anyone who expresses the desire to work. The programs are staffed by employment specialists who work with the treatment team to integrate services. They help people look for jobs soon after entering the program, and provide support as long as consumers want the assistance.

Integrated Dual Disorders Treatment -

This treatment approach is for people who have mental illness and addiction disorders, offering mental health and substance abuse services together, in one setting, at the same time. A wide variety of services are offered in a stage-wise fashion because some services are important early in treatment, while others are important later on.

The EBPs described above are intended for use in the public mental health system, serving people with severe mental illness; they are not diagnosis specific. The American Association of Community Psychiatrists (http://www.wpic.pitt.edu/aacp/default.htm) has released guidelines, such as Guidelines for Recovery Oriented Services that also address this target population rather than a diagnosis specific population.

The American Psychiatric Association has developed diagnosis specific practice guidelines (http://www.psych.org/) that are applicable in a wide variety of settings, as have other professional groups. The following list of behavioral healthcare guidelines and protocols is from the National Guideline Clearinghouse:

>   Adjustment Disorders
>   Anxiety Disorders
>   Delirium, Dementia, Amnestic, Cognitive Disorders
>   Dissociative Disorders
>   Eating Disorders
>   Factitious Disorders
>   Impulse Control Disorders
>   Mental Disorders Diagnosed in Childhood
>   Mood Disorders
>   Neurotic Disorders
>   Personality Disorders
>   Schizophrenia and Disorders with Psychotic Features
>   Sexual and Gender Disorders
>   Sleep Disorders
>   Somatoform Disorders
>   Substance-Related Disorders


EVIDENCE-BASED PRACTICES FOR ALL POPULATIONS -

There are evidence-based practices in clinical preventive services that should be utilized with all populations, whether or not they are receiving services related to a particular diagnosis or condition. This is an area for improvement in services to persons with severe mental illness, who historically have had difficult accessing healthcare services for acute or chronic medical conditions, not to mention clinical screening and prevention services.

The U.S. Preventive Services Task Force (USPSTF) (http://www.ahcpr.gov/clinic/uspstfix.htm) was convened by the U.S. Public Health Service to rigorously evaluate clinical research in order to assess the merits of preventive measures, including screening tests, counseling, immunizations, and chemoprevention. The USPSTF consists of 15 experts from the specialties of family medicine, pediatrics, internal medicine, obstetrics and gynecology, geriatrics, preventive medicine, public health, behavioral medicine, and nursing. The recommended clinical prevention services are organized into the following clinical categories:

>   Cancer
>   Heart and Vascular Diseases
>   Injury and Violence-Related Disorders
>   Infectious Diseases
>   Mental Disorders and Substance Abuse
>   Metabolic, Nutritional, and Endocrine Disorders
>   Musculoskeletal Disorders
>   Obstetric Disorders
>   Pediatric Disorders
>   Vision and Hearing Disorders

The original Task Force's efforts culminated in the 1989 Guide to Clinical Preventive Services. A second edition of the Guide was published in 1996. In November 1998, the Agency for Healthcare Research and Quality (then the Agency for Health Care Policy and Research) convened the current USPSTF to update existing Task Force assessments and recommendations and to address new topics.


CONCLUSION -

The Institute of Medicine's Improving the Quality of Healthcare for Mental and Substance-Use Conditions states: "A large body of research and other published work on organizational change, for example, consistently calls attention to five predominantly human resource management practices (and one other organizational practice) that are key to successful change implementation (1) ongoing communication about the desired change with those who are to effect it; (2) training in the new practice; (3) worker involvement in designing the change process; (4) sustained attention to progress in making the change; (5) use of mechanisms for measurement, feedback, and redesign; and (6) functioning as a learning organization. All of these practices require the exercise of effective leadership."