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

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.

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