Healthcare Providers Policy Planning:The Four Quadrant Model

The 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.