Integrated Four Quadrant Model: Behavioral and Physical Health. UIC College of Nursing

Transcription

1 Integrated Four Quadrant Model: Behavioral and Physical Health UIC College of Nursing

2 Overview of Training Background and Objectives Overview of Integrated Four Quadrant Model History of Development of Integrated Four Quadrant Model What is Behavioral Health Risk/Complexity? What is Physical Health Risk/Complexity? Integrated Four Quadrant Model Classifying Class Members Case Studies and Exercises in Classifying Colbert Class Members Review and Summary 2

3 Background of Training Colbert key players desire: A better understanding A classification model The Integrated Four Quadrant Model is the selected paradigm. 3

4 Background of Training State request: Include Integrated Four Quadrant placement Develop a process Integrate into the current assessment 4

5 Objectives Participants will acquire: An initial understanding of the Integrated Four Quadrant Model. Knowledge on how health risks/complexities are defined Understanding of how the model development and functioning Initial skills to complete placement and record the Quadrant Placement in the Colbert assessment. 5

6 What is the Integrated Four Quadrant Model? 6

7 Colbert Integrated Four Quadrant Model A classification model Determines Behavioral health risk/complexity Physical health risk/complexity. Considers Perceived risk Maintenance of functioning Complexity of illnesses/conditions Acute- and long-term treatment needs (Mauer, 2003; Mauer, 2006; Mauer & Druss, 2010) 7

8 Colbert Integrated Four Quadrant Model Categorizes need as HIGH vs LOW Different combinations of high and low correlate to specific quadrant Behavioral health needs include both mental health/illness and substance use and dependence dimensions 8

9 Colbert Integrated Four Quadrant Model QUADRANT II HIGH Behavioral health LOW Physical health QUADRANT IV HIGH Behavioral health HIGH Physical health QUADRANT I LOW Behavioral health LOW Physical health QUADRANT III LOW Behavioral health HIGH Physical health (Mauer, 2009) 9

10 History of Development of Integrated Four Quadrant Model Primarily based upon The Revised New York Model Initially amended to Four Quadrant Model involving co-occurring Mental Illness and Substance Abuse Recently adapted into Integrated Four Quadrant Model involving Physical Health and Behavioral Health (McGovern, Clark & Samnalievm 2007) (Glover & Gustafson, 1999) 10

11 Quadrant II MH/SU PH Quadrant IV MH/SU PH Low High MH/SU Risk/Complexity Low Outstationed medical nurse practitioner/physician at MH/SU site (with standard screening tools and guidelines) or community PCP MH/SU clinician/case manager w/ responsibility for coordination w/ PCP Specialty outpatient MH/SU treatment including medication-assisted therapy Residential MH/SU treatment Crisis/ED based MH/SU interventions Detox/sobering Wellness programming Other community supports Outstationed medical nurse practitioner/physician at MH/SU site (with standard screening tools and guidelines) or community PCP Nurse care manager at MH/SU site MH/SU clinician/case manager External care manager Specialty medical/surgical Specialty outpatient MH/SU treatment including medication-assisted therapy Residential MH/SU treatment Crisis/ED based MH/SU interventions Detox/sobering Medical/surgical inpatient Nursing home/home based care Wellness programming Other community supports Persons with serious MH/SU conditions could be served in all settings. Plan for and deliver services based upon the needs of the individual, personal choice and the specifics of the community and collaboration. Quadrant I MH/SU PH PCP (with standard screening tools and MH/SU practice guidelines for psychotropic medications and medication-assisted therapy) PCP-based BHC/care manager (competent in MH/SU) Specialty prescribing consultation Wellness programming Crisis or ED based MH/SU interventions Other community supports Quadrant III MH/SU PH PCP (with standard screening tools and MH/SU practice guidelines for psychotropic medications and medication-assisted therapy) PCP-based BHC/care manager (competent in MH/SU) Specialty medical/surgical-based BHC/care manager Specialty prescribing consultation Crisis or ED based MH/SU interventions Medical/surgical inpatient Nursing home/home based care Wellness programming Other community supports Physical Health Risk/Complexity High 11 (Mauer, 2009)

12 Integrated Four Quadrant Model Results in advised service integration Assists service providers in developing patient-centric treatment models Can be used as a conceptual framework and collaborative planning tool Does not predetermine care outcomes Assists in understanding individuals and the population (Glover & Gustafson, 1999; Mauer & Druss, 2010) 12

13 What is Behavioral Health Risk/ Complexity? 13

14 Behavioral Health Mental illness alone Substance abuse alone Comorbidity Behavioral Health Substance Use Mental health Comorbidity 14

15 Behavioral Health Categorization Need considers: Assessed or perceived risk Complexity of illnesses/conditions Past outcomes High vs low based on: Past outcomes Symptom severity Assessor s opinion Risk and Complexity Assessor s opinion Symptom severity 15

16 Variable Selection Research related to pre-morbidity UIC CON analysis of previous Colbert Class members 16

17 Identified Behavioral Health Conditions Anorexia nervosa Bipolar disorder Brief psychotic disorder Bulimia nervosa Delusional disorder Major depressive disorder Post-traumatic stress disorder Psychotic disorder NOS Schizoaffective disorder Schizophrenia Schizophreniform disorder Shared psychotic disorder Substance use disorder (any) 17

18 Behavioral Health Identifiers Condition Severity and Impact on functioning Domain: Diagnosis SMI defined by Rule 132 Number of conditions Domain: Diagnosis SMI defined by Rule

19 Behavioral Health Identifiers Mental illness AND a co-occurring substance Domain: Diagnosis Mental illness AND a previous suicide attempt Domain: Diagnosis 19

20 Behavioral Health Identifiers Intentional physical harm to others in past 30 days Domain: behavioral health Intentional self- harm in past 30 days Domain: behavioral health Psychiatric hospitalization within the past 90 days Domain: Utilization 20

21 Behavioral Health Identifiers Assessor judgment Assessor observation Collateral information Others? Examples: Problematic alcohol use without a diagnosis High risk behaviors 21

22 What is Physical Health Risk/Complexity? 22

23 Physical Health Medical diagnoses and vulnerabilities Acute and chronic Stage or course Complexities of treatment Maintenance control Stage or course Acute vs chronic Physical Health Control Complexities of treatment 23

24 Physical Health Categorization Need considers: Assessed or perceived risk Complexity of illnesses/conditions High vs low based on: Past outcomes Symptom severity Assessor s opinion Specific comorbidities Risk and Complexity Assessor s opinion Past outcomes Symptom severity 24

25 Variable Selection Literature focus on individual diseases Unable to find a concise assessment Defined from experience UIC CON analysis of previous Colbert Class members 25

26 Identified Physical Health Conditions 1 Acute myocardial infarction/heart attack AIDS or symptomatic HIV Cancer (not in remission) Cardiovascular disease (hypertension, high cholesterol, coronary artery disease, angina) Cerebrovascular accident (stroke or transient ischemic attack) Congestive heart failure Chronic lung disease (COPD, emphysema) 26

27 Identified Physical Health Conditions 2 Chronic pain (treated with narcotic medication) Current or chronic wounds Diabetes (requiring insulin and/or Hemoglobin A1c over 7) Kidney disease (requiring dialysis) Liver disease (hepatitis, cirrhosis) Neurodegenerative disorder (dementia, Alzheimer s disease, Parkinson s disease) Seizures (frequent/uncontrolled) TBI 27

28 Physical Health Identifiers Condition Severity and Impact on functioning Domain: Diagnosis Number of conditions Domain: Diagnosis 28

29 Physical Health Identifiers Hospitalization within the past 90 days Domain: Utilization SMI combined with ALL of the following: obesity, any cardiovascular disease and/or diabetes, IADL/self-management deficits, and long-term psychiatric medication management Domains: Diagnosis, Functional, Health Status, Medication 29

30 Physical Health Identifiers Assessor judgment Assessor observation Collateral information Others? Examples: Frequent falls Paralsysis 30

31 Integrated Four Quadrant Model for Classifying Class Members 31

32 Integrated Four Quadrants QUADRANT II HIGH Behavioral health LOW Physical health QUADRANT IV HIGH Behavioral health HIGH Physical health QUADRANT I LOW Behavioral health LOW Physical health QUADRANT III LOW Behavioral health HIGH Physical health 32

33 PART 1: Information Based on REFERRAL OUTCOME Member requires daily 24-hour nursing care due to: 1. Severe dementia Yes = STOP - Quadrant III No = Continue to 2 33

34 PART 1: Information Based on REFERRAL OUTCOME Member requires daily 24-hour nursing care due to: 2. Severe cognitive impairments Yes = STOP - If due to physical health reason, it is Quadrant III. If due to SMI, it is Quadrant II No = Continue to 3 34

35 PART 1: Information Based on REFERRAL OUTCOME Member requires daily 24-hour nursing care due to: 3. Irreversible and declining medical condition Yes = STOP - Quadrant III No = If no for all three, continue to Part 2 35

36 PART 2: Behavioral Health Diagnosis Current Check if yes Severity Anorexia nervosa Bipolar disorder Brief psychotic disorder Bulimia nervosa Delusional disorder Major depressive disorder Post-traumatic stress disorder Psychotic disorder NOS Schizoaffective disorder Schizophrenia Schizophreniform disorder Shared psychotic disorder Substance use disorder 36

37 Part 2: Behavioral Health Severity Index Rating 0 = Asymptomatic, no treatment needed at this time. 1 = Symptoms well-controlled with current therapy. 2 = Symptoms controlled with difficulty, affecting daily functioning; the class member needs ongoing monitoring. 3 = Symptoms poorly controlled or advanced stage disease; the class member needs frequent adjustment in treatment and close monitoring. 4 = Symptoms poorly controlled or advanced stage disease; history of re-hospitalizations and/or multiple emergency room visits. 37

38 Part 2: Behavioral Health Does the class member have any ONE of the above conditions with a rating of 2 or higher? Does the class member have TWO or more of the above conditions of any rating? Does the class member have a mental illness AND a cooccurring substance use disorder of any rating? If the class member has a mental illness, do they have a previous suicide attempt? 38

39 Part 2: Behavioral Health Has the class member physically harmed another individual with intent during the past 30 days? Has the class member physically harmed themselves with intent during the past 30 days? If the class member has a mental illness, have they been psychiatrically hospitalized within the past 90 days? Does the assessor identify any other member characteristics that would place the individual at high behavioral health risk/complexity? 39

40 Part 2: Behavioral Health At this point, before moving to the Physical Health Portion you will classify the class member as high or low need for behavioral health. High Behavioral Health is A. High in Mental Illness alone B. High in Substance Abuse alone C. High in both MI and SA 40

41 Part 2: Physical Health Diagnosis Acute myocardial infarction/heart attack AIDS or symptomatic HIV Cancer (not in remission) Cardiovascular disease (hypertension, high cholesterol ) Cerebrovascular accident (stroke or transient ischemic attack) Congestive heart failure Chronic lung disease (COPD, emphysema) Chronic pain (treated with narcotic medication) Current or chronic wounds Diabetes (requiring insulin and/or Hemoglobin A1c over 7) Kidney disease (requiring dialysis) Liver disease (hepatitis, cirrhosis) Neurodegenerative disorder (dementia, Alzheimer s disease ) Current Check if yes Severity Seizures (frequent/uncontrolled) 41 TBI

42 Part 2: Physical Health Severity Index Rating 0 = Asymptomatic, no treatment needed at this time. 1 = Symptoms well-controlled with current therapy. 2 = Symptoms controlled with difficulty, affecting daily functioning; the class member needs ongoing monitoring. 3 = Symptoms poorly controlled or advanced stage disease; the class member needs frequent adjustment in treatment and close monitoring. 4 = Symptoms poorly controlled or advanced stage disease; history of re-hospitalizations and/or multiple emergency room visits. 42

43 Part 2: Physical Health Does the class member have any ONE of the above conditions with a rating of 2 or higher? Does the class member have TWO or more of the above conditions of any rating? Has the class member been hospitalized in the past 90 days for one of the above diagnoses? 43

44 Part 2: Physical Health Does the class member have a SMI combined with ALL of the following: obesity, any cardiovascular disease and/or diabetes, IADL/self-management deficits, and long-term psychiatric medication management? Does the assessor identify any other member characteristics that would place the individual at high physical health risk/complexity? 44

45 Part 2: Physical Health At this point, before moving to the Quadrant Placement you will classify the class member as high or low need for physical health. High Behavioral Health is A. High in severity B. High in complexity C. High in both severity and complexity 45

46 PART 3: QUADRANT PLACEMENT Based on the need levels identified in Behavioral Health and Physical Health, please circle the appropriate final complexity level: Final Behavioral Health Risk/Complexity Member has been identified as LOW or HIGH Behavioral Health Risk/Complexity Final Physical Health Risk/Complexity Member has been identified as LOW or HIGH Physical Health Risk/Complexity 46

47 Integrated Four Quadrants QUADRANT II HIGH Behavioral health LOW Physical health QUADRANT IV HIGH Behavioral health HIGH Physical health QUADRANT I LOW Behavioral health LOW Physical health QUADRANT III LOW Behavioral health HIGH Physical health 47

48 PART 3: QUADRANT PLACEMENT Based on the final behavioral and physical health risk/complexity identified above, please check member s appropriate quadrant placement. QUADRANT II HIGH Behavioral Health Risk/Complexity LOW Physical Health Risk/Complexity QUADRANT IV HIGH Behavioral Health Risk/Complexity HIGH Physical Health Risk/Complexity QUADRANT I LOW Behavioral Health Risk/Complexity LOW Physical Health Risk/Complexity QUADRANT III LOW Behavioral Health Risk/Complexity HIGH Physical Health Risk/Complexity 48

49 Case Study #1 Dave Chappelle 49

50 PART 3: QUADRANT PLACEMENT Based on the final behavioral and physical health risk/complexity identified above, please check member s appropriate quadrant placement. QUADRANT II HIGH Behavioral Health Risk/Complexity LOW Physical Health Risk/Complexity QUADRANT IV HIGH Behavioral Health Risk/Complexity HIGH Physical Health Risk/Complexity QUADRANT I LOW Behavioral Health Risk/Complexity LOW Physical Health Risk/Complexity QUADRANT III LOW Behavioral Health Risk/Complexity HIGH Physical Health Risk/Complexity 50

51 Answer Dave is low for both Behavioral and Physical Health Risk/Complexity Dave is placed in Quadrant I. 51

52 Case Study #2 Denzela Washington 52

53 PART 3: QUADRANT PLACEMENT Based on the final behavioral and physical health risk/complexity identified above, please check member s appropriate quadrant placement. QUADRANT II HIGH Behavioral Health Risk/Complexity LOW Physical Health Risk/Complexity QUADRANT IV HIGH Behavioral Health Risk/Complexity HIGH Physical Health Risk/Complexity QUADRANT I LOW Behavioral Health Risk/Complexity LOW Physical Health Risk/Complexity QUADRANT III LOW Behavioral Health Risk/Complexity HIGH Physical Health Risk/Complexity 53

54 Answer Denzela is Low Behavioral Health Risk/Complexity and High Physical Health Risk/Complexity. Denzela is placed into Quadrant III. 54

55 Case Study #3 Gary Busey 55

56 PART 3: QUADRANT PLACEMENT Based on the final behavioral and physical health risk/complexity identified above, please check member s appropriate quadrant placement. QUADRANT II HIGH Behavior Health Risk/Complexity LOW Physical Health Risk/Complexity QUADRANT IV HIGH Behavior Health Risk/Complexity HIGH Physical Health Risk/Complexity QUADRANT I LOW Behavior Health Risk/Complexity LOW Physical Health Risk/Complexity QUADRANT III LOW Behavior Health Risk/Complexity HIGH Physical Health Risk/Complexity 56

57 Answer Gary is High Behavioral Health Risk/Complexity and Low Physical Health Risk/Complexity. Gary is placed in Quadrant II. 57

58 Case Study #4 Oprah Winfrey 58

59 PART 3: QUADRANT PLACEMENT Based on the final behavioral and physical health risk/complexity identified above, please check member s appropriate quadrant placement. QUADRANT II HIGH Behavioral Health Risk/Complexity LOW Physical Health Risk/Complexity QUADRANT IV HIGH Behavioral Health Risk/Complexity HIGH Physical Health Risk/Complexity QUADRANT I LOW Behavioral Health Risk/Complexity LOW Physical Health Risk/Complexity QUADRANT III LOW Behavioral Health Risk/Complexity HIGH Physical Health Risk/Complexity 59

60 Answer Oprah is High Behavioral Health Risk/Complexity and High Physical Health Risk/Complexity. Oprah is placed in Quadrant IV. 60

61 Discussion 61

62 References 62

63 References Glover, R. W., & Gustafson, J. S. (1999). National Dialogue on Co-Occurring Mental Health and Substance Abuse Disorders. Retrieved December 18, 2017 from Mental-Health-and-Substance-Abuse-Disorders-1998.pdf Keyser, D. J., Watkins, K. E., Vilamovska, A., & Pincus, H. A. (2008). Improving service delivery for individuals with co-occurring disorders: New perspectives on the quadrant model.psychiatric Services, 59(11), doi: /appi.ps Mauer, B. J. (2003). Background paper: Behavioral health/primary care integration models, competencies, and infrastructure. Rockville, Maryland: National Council for Community Behavioral Healthcare (NCCBH). Retrieved from /about-us/mauers_behav_health_models_ Competencies_Infra.pdf Mauer, B. J. (2006). Behavioral Health/Primary Care Integration: The Four Quadrant Model and Evidence-Based Practices. Rockville, Maryland: National Council for Community Behavioral Healthcare (NCCBH). Retrieved from Mauer, B. (2009). Behavioral health/primary care integration and the person-centered healthcare home. National Council for Community Behavioral Healthcare. Washington, DC. Retrieved from MH-2009.pdf 63

64 References Mauer, B. J., & Druss, B. G. (2010). Mind and body reunited: Improving care at the behavioral and primary healthcare interface. The journal of behavioral health services & research, 37(4), McDonell, M. G., Kerbrat, A. H., Comtois, K. A., Russo, J., Lowe, J. M., & Ries, R. K. (2012). Validation of the co-occurring disorder quadrant model. Journal of Psychoactive Drugs, 44(3), / McGovern, M. P., Clark, R. E., & Samnaliev, M. (2007). Co-occurring Psychiatric and Substance Use Disorders: A Multistate Feasibility Study of the Quadrant Model. Psychiatric Services, 58(7), Minkoff, K. (2000). An Integrated Model for the Management of Co-Occurring Psychiatric and Substance Disorders in Managed-Care Systems: Disease Management and Health Outcomes, 8(5), Minkoff, K. (2001). Program components of a comprehensive integrated care system for seriously mentally ill patients with substance disorders. New Directions for Mental Health Services, 2001(91),

65 References Sacks, S., & Ries, R. K. (2005). Substance Abuse Treatment for Persons With Co-Occurring Disorders. Treatment Improvement Protocol (TIP) Series 42. Substance Abuse and Mental Health Services Administration. Shackelford, J. R., Sirna, M., Mangurian, C., Dilley, J. W., & Shumway, M. (2013). Descriptive Analysis of a Novel Health Care Approach: Reverse Colocation Primary Care in a Community Mental Health Home. The Primary Care Companion for CNS Disorders, 15(5). 65

66 Conclusion