Healthcare Providers Policy Planning:The Four Quadrant Model
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