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

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

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