The Four Quadrant Model for Integrating Health Care for Mental Health and Substance Abuse Patients

The Four Quadrant Model is a proposed model for the clinical integration of mental health and behavioral health services. A focus on the prevalence of co-occurring disorders (i.e. depression and alcoholism) is paramount in this model. The Four Quadrant Model builds on the 1998 consensus document for mental health and substance abuse/addiction service integration. This model for a comprehensive, continuous and integrated system of care describes differing levels of mental health and substance abuse integration and clinician competencies based on the four-quadrant model, divided into severity for each disorder:

>    Quadrant I: Low mental health – low substance abuse, served in primary care
>    Quadrant II: High mental health – low substance abuse, served in the mental health system by staff who have substance abuse competency
>    Quadrant III: Low mental health – high substance abuse, served in the substance abuse system by staff who have mental health competency
>    Quadrant IV: High mental health – high substance abuse, served by a fully integrated mental health and substance abuse program

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 behavioral health and community mental healthcare site, with the local provider(s) of public behavioral health 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 behavioral health – low physical health complexity/risk, served in primary care with behavioral health care staff on site; very low/low individuals served by the principle care provider, with the behavioral health care staff serving those with slightly elevated health or behavioral health risk.

The principle care providers give primary care services and uses standard behavioral health screening tools and practice guidelines to serve most individuals in the primary care practice. Use of standardized behavioral health tools by the principle care providers and a tracking/registry system focuses referrals of a subset of the population to the behavioral health clinician. The role of the primary care based behavioral health clinician is to provide formal and informal consultation to the principle care providers as well as to provide behavioral health triage and assessment, brief treatment services to the patient, referral to community and educational resources, and health risk education. Behavioral health clinical and support services may include individual or group services, use of cognitive behavioral therapy, psycho-education, brief substance abuse intervention, and limited case management. The behavioral health clinician must be competent in both mental health and substance abuse assessment and service planning. The principle care provider 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 behavioral health 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 serious persistent mental illness who are currently stable, which should be based upon consumer choice and the specifics of the community collaboration.

QUADRANT II

High behavioral health – low physical health complexity/risk, served in a specialty behavioral health system that coordinates with the principle care providers.

The principle care provider provides primary care services and collaborates with the specialty behavioral health providers to assure coordinated care for individuals. Psychiatric consultation for the principle care providers may be an element in these complex behavioral health situations, but it more likely that psychotropic medication management will be handled by the specialty behavioral health system. The role of the specialty behavioral health clinician is to provide behavioral health assessment, arrange for or deliver specialty behavioral health 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 behavioral health 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 behavioral health systems including:

Specialty Mental Health 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
>    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 Substance Abuse 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 behavioral health consumers)

Supports for Serious Persistent Mental Health 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 behavioral health clinician must be competent in both mental health and substance abuse assessment and service planning. A specific standard of practice should be adopted that defines the methods and frequency of communication with principle care providers. Note that this quadrant is where most public sector behavioral health consumers currently can be found.

QUADRANT III

Low behavioral health – high physical health complexity/risk, served in the primary care/medical specialty system with behavioral health staff on site in primary or medical specialty care, coordinating with all medical care providers including disease managers.

The principle care providers 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 behavioral health screening tools and practice guidelines to serve most individuals in the primary care practice. Use of standardized behavioral health tools by the principle care providers and a tracking/registry system focuses referrals of a subset of the population to the behavioral health clinician. The role of the primary care or medical specialty based behavioral health clinician is to provide behavioral health triage and assessment, consultation to the principle care providers or treatment services to the patient, referral to community and educational resources, and health risk education. Behavioral health clinical and support services may include individual or group services, use of cognitive behavioral therapy, psycho-education, brief substance abuse intervention, and limited case management. The behavioral health clinician must be competent in both mental health and substance abuse assessment and service planning. The principle care provider prescribes psychotropic medications using treatment algorithms and has access to psychiatric consultation regarding medication management.

Depending on the setting, the behavioral health 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). These population-based services, as articulated by Bob Dyer, would include: patient education, activity planning; prompting; skill assessment; skill building; and, mutual support. In addition to these disease management services, the behavioral health 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 behavioral health – high physical health complexity/risk, served in both the specialty behavioral health and primary care/medical specialty systems; in addition to the behavioral health 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 principle care providers 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 behavioral health system in the planning and delivery of behavioral health 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 behavioral health clinician is to provide behavioral health assessment, arrange for or deliver specialty behavioral health services, assure case management related to housing and other community supports, and collaborate at a high level with the healthcare system team. The behavioral health clinician must be competent in both mental health and substance abuse assessment and service planning.

In some settings, behavioral health services may be integrated with specialty provider teams (for example, Kaiser has behavioral health 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 behavioral health 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.